Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient surgery and pay for the self-administered drugs provided on September 6, 2019.
You asked the Plan to waive the copayment for the outpatient surgery and pay for the self-administered drugs. You say that this should not be your responsibility. The Plan denied your request. The Plan says that this processed correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for outpatient hospital surgery services. The rules also say that Medicare Part B generally does not pay for self-administered drugs.
You have been asked to pay a $250 copayment for the outpatient surgery. The outpatient surgery falls within the outpatient hospital surgery services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to waive the copayment for the outpatient surgery and pay for the self-administered drugs provided on September 6, 2019.
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient mental health services provided on February 12, 2019
You asked the Plan to pay for the outpatient mental health services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were non-emergent and no preauthorization was on file. There are in-network providers that could provide the services at issue.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the outpatient mental health services provided on February 12, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physician services provided from August 24, 2019 to August 25, 2019.
You asked the Plan to waive the copayment for physician services. You say that you only met this provider while you were an inpatient at Milford Regional. You say that you never saw him in an office. The Plan denied your request. The Plan says the correct copayment has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $15 copayment for physician/practitioner services/primary care doctor. You have been asked to pay a $15 copayment for physician services. When medically-necessary care is furnished in an outpatient hospital department or any other location, a copayment is applied; therefore, the correct copayment has been applied. Physician services fall within the physician/practitioner services/primary care doctor benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for physician services provided from August 24, 2019 to August 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1851) and suspension sleeve (L2397) provided May 29, 2019.
You asked the Plan to pay for the orthoses. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says there is no evidence of an established relationship between the enrollee and the ordering physician, there was no claims submitted for an evaluation and management service and there is no evidence of a prior telehealth service with the ordering physician as required per CMS guidelines.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the non-covered visit are likewise non-covered. Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1851) and suspension sleeve (L2397) provided May 29, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered on May 7, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure codes J2780 and 96375 are not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code J2780 is injection, ranitidine hydrochloride, 25 mg. The definition of code 96375 is therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of a new substance/drug (List separately in addition to code for primary procedure). We find that CPT codes J2780 and 96375 are not supported in the medical record. Specifically, there is no documentation of the billed drug name and administration dosage to support code J2780 and no dcumentation that therapeutic, prophylactic, or diagnostic injections were performed to support code 96375. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the services rendered on May 7, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forEmergency Room (E.R.) services provided May 5, 2019 by "the hospital". You asked the Plan to waive the copayment forthe E.R. visit. You say that the copayments should be waived.The Plan denied your request. The Plan says the correct copayment was applied.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 copayment for Emergency Care. You have been asked to pay a $100 copayment for the E.R. visit. The E.R. visit falls within the Emergency Care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forEmergency Room (E.R.) services provided May 5, 2019 by "the hospital".
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the paramedic intercept services provided on April 4, 2019.
You asked the Plan to pay for the paramedic intercept services. You say that you did not request the paramedic. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare pays for advanced life support (ALS) paramedic intercept services only when the services are furnished under a contract with a qualified basic life support (BLS) volunteer ambulance company. In addition, State law must not allow the volunteer ambulance company to bill for the transport or BLS services. The Plan has confirmed that ALS Unit does not have a contract with the volunteer ambulance company that provided the transport services. Therefore, we decided that the Plan does not have to pay for the paramedic intercept services provided on April 4, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a diagnostic mammogram (G0279) provided on August 19, 2019.
You asked the Plan to waive the coinsurance for the mammogram. You say that the coinsurance should be waive since the first test was unclear. The Plan denied your request. The Plan says the correct coinsurance has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 10% coinsurance for Diagnostic Testing. You have been asked to pay a 10% coinsurance for the mammogram. The mammogram falls within the Diagnostic Testing benefit category. While the initial test was a screening mammogram with no coinsurance per Medicare rules, because of the inconclusive results the second exam was coded as a Diagnostic Mammogram. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for a diagnostic mammogram (G0279) provided on August 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four testing provided to the enrollee on October 26, 2018.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says train of four is considered a bundled procedure, and payment for it is included in the payment for the already approved neuoromonitoring.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 95999 is "Unlisted neurological or neuromuscular diagnostic procedure." We find that CPT code 95999 is not supported in the medical record. Specifically, payment for this code was included in the payment for the already approved codes. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for train of four testing provided to the enrollee on October 26, 2018.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care provided on April 24, 2019 by out of network provider.You asked the Plan to pay for the subsequent hospital care. You say that your provider treated the enrollee while hospitalized, and depends upon the hospital staff to verify eligibility and obtain the proper authorizations.The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. The plan says that non-emergent services with non-contracted providers require prior-authorization prior to services being rendered Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay for the subsequent hospital care provided on April 24, 2019 by out of network provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the ophthalmic biometry services provided on August 8, 2019 by the out of network provider.
You asked the Plan to pay for the ophthalmic biometry services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the ophthalmic biometry services provided on August 8, 2019 by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 99152) provided to the enrollee on September 18, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the documentation submitted did not include documentation of the presence of an independent trained observer.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99152 is "Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older". We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the use of CPT code 99152 is not supported by the records provided. Our physician reviewer found that the documentation does not note who provided the independent observation of the patient while the physician performed the procedure. Such documentation might include noting the person in the procedure note or providing that person's independent documentation. Therefore, the billing of CPT 99152 is not supported. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services (CPT 99152) provided to the enrollee on September 18, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for observation services from September 5, 2019 through September 6, 2019.
You asked the Plan to waive the copayment for observation services. You say that you do not know why you have to pay $200 when this was an emergency room (ER) visit. You state that you should only have a copay for an ER visit because you were never admitted to the hospital. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received observation services from September 5, 2019 through September 6, 2019.The medical records that the doctor recommended admission for observation. You were presented with and signed a Medicare Outpatient Observation Notice (MOON) at 12:05AM on September 6, 2019. This notice advised you that you were hospital outpatient receiving observation services and being an outpatient may affect what you pay in a hospital. You are asked to pay a $200 copayment for the observation stay. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for observation services from September 5, 2019 through September 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided by an out-of-network provider on February 18, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services were not authorized.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay forthe medical services provided by an out-of-network provider on February 18, 2019
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not haveto pre-approve Euflexxa (J7323).You asked the Planto pre-approve Euflexxa. You say that the requested medication is necessary.The Plandenied your request. The Plansaysbased on the documentation provided, coverage criteria for a step therapy exception has not been met.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Euflexxa. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the documentation does not support that Orthovisc and Monovisc would likely be less effective, and/or would likely have adverse effects for the enrollee in this case.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa have not been met.Therefore, we decided that the Plandoes not haveto pre-approveEuflexxa (J7323)
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography colonography (CTC) screening.You asked the Plan to pre-approvethese services. You say that the enrollee has never had a screening colonoscopy and is at high risk for sedation for a colonoscopy.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. The rules say that screening computed tomographic colonography (CTC) is non-covered.The services at issue are a CTC for screening. These services are non-covered by Medicare.Therefore, we decided that the Plan does not have to pre-approvea computed tomography colonography (CTC) screening.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on July 26,
2019.
You asked the Plan to pay for drug tests. You say that you have submitted a valid laboratory requisition form.
The Plan denied your request. The Plan says the denial of payment for these services is correct, because the
documentation submitted does not include a valid physician order, lab requisition, or medical records to
support the tests billed.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific
lab services is required for covered lab services.
We looked at the file and Medicare rules. The documentation submitted does not include a physician order or
clear intent to order the specific lab tests billed on this claim. Based on this information, we decided that
Medicare rules for coverage of drug tests have not been met. Therefore, we decided that the Plan does not have
to pay for drug testing provided on July 26, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvePantoprazole for "the enrollee".You asked the Plan to pre-approvePantoprazole. The Plan denied your request. The Plan says drug coverage is limited to Medicare Part B covered drugs.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approve Pantoprazole for "the enrollee" Benefits for Pantoprazolemay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vascepa capsules.
You asked the Plan to pre-approve self-administered drugs. You say that the enrollee cannot tolerate other medications. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Vascepa capsules.
Benefits for self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.