Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit and does not have to waive the coinsurance for a Medicare Part B Drug injection provided on September 27, 2019.
You asked the Plan to waive the copayment for a specialist visit and to waive the coinsurance for a Medicare Part B Drug injection. You say that you disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
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 $50 copayment for each specialist visit. Your contract with the Plan also clearly says that you must pay 20% coinsurance for Medicare Part B prescription drugs. You had a specialist visit on September 27, 2019. Therefore, you are responsible to pay the $50 copayment. You received a Medicare Part B prescription drug on September 27, 2019. The allowed amount is $3,000 and 20% of that is $600.00. The total amount you owe is: $650.00. You have been asked to pay the total amount of $650.00 for a specialist visit and a Medicare Part B Drug injection. A specialist visit falls within the physician/practitioner services, including doctor's office visits benefit category. A Medicare Part B drug falls within the Medicare Part B prescription drugs 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 a specialist visit and does not have to waive the coinsurance for a Medicare Part B Drug injection provided on September 27, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for Emergency Clinic services provided May 25, 2019.
You asked the Plan to pay for the Emergency Clinic services. You say that the services were medically necessary. The Plan denied your request. The Plan says records show the provider is not affiliated with a hospital.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that the services at issue are not eligible for Medicare reimbursement. Specifically, the record shows the provider is not affiliated with a hospital. Medicare only allows payment for freestanding Emergency Clinics when the clinic is affiliated with a hospital. Based on this information, we decided that Medicare rules for coverage of the Emergency Clinic services have not been met. Therefore, we decided that the Plan does not have to pay for Emergency Clinic services provided May 25, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for needle electromyography (95870) provided on September 24, 2018.You asked the Plan to pay for needle electromyography. You say that this procedure is clearly documented.The Plan denied your request. The Plan says there must be some indication that needle electrodes were placed in order to support needle EMG was performed.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 95870 is needle electromyography; limited study of muscles in 1 extremity or non-limb (axial) muscles (unilateral or bilateral), other than thoracic paraspinal, cranial nerve supplied muscles, or sphincters.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 needle electromyography. Our reviewer says that CPT 95870 is not supported by the record. Our physician reviewer found the medical documentation submitted does not indicate that needle electrodes were placed/inserted in order to validate that a Needle electromyography; limited study of muscles in 1 extremity or non-limb (axial) muscles (unilateral or bilateral), other than thoracic paraspinal, cranial nerve supplied muscles, or sphincters was performed on September 24, 2019. Therefore, the service cannot be verified.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of needle electromyography have not been met.Therefore, we decided that the Plan does not have to pay forneedle electromyography (95870) provided on September 24, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the annual wellness visit, office visit and immunizations provided on September 16, 2019.
You asked the Plan to waive the cost share for the annual wellness visit, office visit and immunizations. You say that these should be covered as preventive benefits. You say that you should be reimbursed. The Plan denied your request. The Plan says the cost share applied 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 30% of the allowed amount for an out-of-network annual wellness visit, $40 copayment for each out-of-network primary care provider office visit and 30% of the allowed amount for the pneumonia, influenza, and Hepatitis B vaccines from an out-of-network provider. You have been asked to pay a total of $120.68 for the annual wellness visit, office visit and immunizations.
Service
Allowed Amount
Standard Out-Of-Network Cost
Member Liability
Annual Wellness Visit
$115.43
30%
$34.63
Office Visit
$107.76
$40
$40
Immunizations
$153.47
30%
$46.05
TOTAL:
$120.68
The annual wellness visit falls within the "Annual wellness visit" benefit category. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The immunizations fall within the "Immunizations" 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 cost share for the annual wellness visit, office visit and immunizations provided on September 16, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for
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 these codes are not valid for Medicare purposes.
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 definition of the denied codes is: HCPCS S1015: IV tubing extension set HCPCS S8301: Infection control supplies, not otherwise specified We find that the denied codes are not supported in the medical record. Specifically, these codes have a status indicator of I according to the Medicare Physician's Fee Schedule. This indicates that the codes are not valid for Medicare purposes. 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
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of VISCO-3.
You asked the Plan to pre-approve VISCO-3. You say that you have had this procedure re-scheduled multiple times and cannot go much longer. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because the Plan requires a trial of Orthovisc or Monovisc before it will approve VISCO-3.
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 VISCO-3. Our reviewer says that you do not meet the Medicare criteria for a step therapy exception for VISCO-3. Our physician reviewer found you have not tried and failed the Plan's preferred drugs of Orthovisc or Monovisc. The documentation does not support that Orthovisc and Monovisc would likely be less effective and/or would likely have adverse effects for you. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of VISCO-3 have not been met. Therefore, we decided that the Plan does not have to pre-approve use of VISCO-3.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided to the Enrollee on September 18, 2019.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order/lab requisition or medical records.

The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided to the Enrollee on September 18, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services provided to the enrollee on August 22, 2019.
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 it is inappropriate to report a procedure both as a global service and as the technical or professional components.
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 76536 is "Ultrasound, soft tissues of head and neck (eg, thyroid, parathyroid, parotid), real time with image documentation." We find that CPT code 76536 is not supported in the medical record. Specifically, this code cannot be reported twice. The global service can be allowed, but the technical and professional and technical components are not supported in the case file. 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 radiology services provided to the enrollee on August 22, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient mental health services.
You asked the Plan to pre-approve inpatient care. The Plan denied your request. The Plan says you do not
express a plan or intent to hurt yourself or others.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the
patient requires active treatment.
Continued care beyond January 30, 2020 was requested. 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 inpatient care. Our physician reviewer found that based on the records provided, you do not appear
to require inpatient mental health treatment as you are not a danger to yourself or others. You are cooperative
and compliant. It does not appear that active treatment is taking place. The services are not reasonably expected
to improve your condition, or for the purpose of diagnosis. You are without agitation or aggression, without
perceptual disturbance including auditory, or visual hallucinations.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of inpatient care have not been met. Therefore, we decided that the Plan does not
have to pre-approve continued inpatient mental health services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora specialist visit provided by "the doctor" on October 2, 2019.You asked the Plan to waive the copayment fora specialist visit. You say that this was a follow-up visit and you should not be responsible for the charges.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.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 $50 copayment for specialist visits. You had a specialist visit on October 2, 2019. Follow-up visits are subject to cost-sharing charges. Therefore, you are responsible to pay the $50 copayment. You have been asked to pay a $50 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits 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 fora specialist visit provided by "the doctor" on October 2, 2019.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a Dexcom G6 transmitter, receiver and sensor.
You asked the Plan to pre-approve the Dexcom G6 transmitter, receiver and sensor. You say that the doctor changed to this device because she had an allergic reaction to the Freestyle Libre. The Plan denied your request. The Plan says that the enrollee does not meet the prior authorization criteria and the requested device is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the plan did not provide us with any medical records or evidence of having made reasonable attempts to obtain this necessary information. Without medical records, we are unable to assess whether the plan's contracted provider/device is adequate to meet the enrollee's medical needs. Without the medical records, the plan has not substantiated their denial reason. Therefore, we decided that the Plan has to pre-approve a Dexcom G6 transmitter, receiver and sensor.
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 April 17, 2019.
You asked the Plan to pay for the 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 for the medical services provided by an out-of-network provider on April 17, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Multaq tablets.You asked the Plan to pre-approve self-administered drugs. You say that the enrollee has started therapy with this drug and needs to continue.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 also says that the enrollee may receive commercial pharmacy benefits from the plan, which provides its own pharmacy 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-approveMultaq tablets.Benefits for self-administered drugsmay 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 Prolia.
You asked the Plan to pre-approve the Prolia. You say that the enrollee has a previous diagnosis and continued monitoring of kidney lesion, as well as chronic COPD that requires long term maintenance with inhaled/oral systemic steroid treatments. You say that, because of these reasons, Prolia is the best choice of treatment for the enrollee's osteoporosis due to secondary cause of corticosteroid use. The Plan denied your request. The Plan says the criteria for coverage have not been met. The plan says that the enrollee's physician has not demonstrated why it is medically necessary to make an exception for the enrollee.
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 the Prolia. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the provided medical records show that the enrollee has had prior treatment with alendronate, but not with zoledronic acid. The provided medical records indicate a diagnosis of gastroesophageal reflux disease which can be a contraindication to an oral bisphosphonate, but this does not apply to zoledronic acid. There is a report of a renal lesion but the latest lab data in the records from March 1, 2019 shows normal renal function with a creatinine level of 0.66 and a glomerular filtration rate > 60. There appears to be no contraindication to zoledronic acid.
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 Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided to the enrollee on September 17, 2019.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order/lab requisition or medical records stating exactly what tests are to be performed.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided to the enrollee on September 17, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for ESRD services provided to the enrollee from January 3, 2019 to January 31, 2019.
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 there is an invalid/missing value code.
The Plan must follow Medicare rules. Medicare rules say that ESRD services require a value code. The case file does not contain a valid value code for these services. 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 ESRD services provided to the enrollee from January 3, 2019 to January 31, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on June 18, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network deficiency for these services.
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 for the medical services provided to the enrollee by an out-of-network provider on June 18, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rhopressa solution.
You asked the Plan to pre-approve self-administered drugs. You say that without this medication, the enrollee's condition will worsen and could result in blindness. 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 Rhopressa solution.