Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from November 7, 2018 through November 8, 2018.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you were in the hospital over a year ago and the hospital did not inform you that you would owe anything. The Plan denied your request. The Plan says the claim was processed accordingly with your 2018 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 inpatient hospital care from November 7, 2018 through November 8, 2018. You are asked to pay a $225 copayment for day 1 of your inpatient hospital care, November 7, 2018. You were discharged on November 8, 2018 and there was no copayment charge for the day of discharge. Per your contract there is a $225 copayment per day required for days 1-5. 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 inpatient hospital care from November 7, 2018 through November 8, 2018.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for an emergency department visit (99285) provided on June 24, 2019.
You asked the Plan to pay for the emergency department visit. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says services that are considered column II procedures to another service are not eligible for reimbursement when billed with the column I procedure code.
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, we have confirmed that code the emergency department visit has a bundled relationship with code 99283 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for an emergency department visit (99285) provided on June 24, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lantus for the enrollee.
You asked the Plan to pre-approve this drug. The Plan denied your request. The Plan says that this is not covered under Part B.
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 Lantus for the enrollee.
Benefits for this drug 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a drug test provided on November 1, 2019 by an out of network (OON) provider.
You asked the Plan to pay for a drug test. You say that you would like this case reviewed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the referring provider is out-of-network.
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 a drug test provided on November 1, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor and supplies for the enrollee.
You asked the Plan to pre-approve these services. You say that the enrollee would benefit greatly by having this device. The Plan denied your request. The Plan says that a non-preferred brand is not covered without a reason the non-preferred cannot be used.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 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 these services. Our reviewer says that these services are not medically reasonable and necessary for the enrollee in this case. At the time of the application for these items, the enrollee is taking 1 shot of insulin. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for these services. We looked at this physician's review, the file, and Medicare rules. 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 pre-approve a Dexcom G6 continuous glucose monitor and supplies for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tier exception for Accu-Chek Aviva Plus test strips for the enrollee.
You asked the Plan to pre-approve a tier exception. The Plan denied your request. The Plan says that tier exceptions only apply to Part D drugs.
The Plan must follow Medicare rules. Medicare rules say that tier exceptions are only available for Part D drugs. The requested items are durable medical equipment. Based on this information, we decided that Medicare rules for coverage of a tier exception have not been met. Therefore, we decided that the Plan does not have to pre-approve a tier exception for Accu-Chek Aviva Plus test strips for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eliquis for the enrollee.You asked the Plan to pre-approve this drug. The Plan denied your request. The Plan says that this is not covered under Part B.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 Eliquis for the enrollee.Benefits for this drug 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 18, 2019 by an out of network (OON) provider.
You asked the Plan to pay for genetic tests. You say that these tests are supported as medically necessary. The Plan denied your request. The Plan says the denial of payment for these services is correct, because these tests are experimental or investigational and are not covered.
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. Prior authorization was requested for this testing and denied by the Plan. 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 medical services provided on October 18, 2019 by an out of network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital inpatient visit provided on November 4, 2019.
You asked the Plan to pay for the hospital inpatient visit. You say that the payment for the hospital inpatient visit was reduced. You say the services were medically necessary. The Plan denied your request. The Plan says the Medicare hospice benefits covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. The record shows proof of hospice election from November 4, 2019 to November 6, 2019. Therefore, we decided that the Plan does not have to pay for the hospital inpatient visit provided on November 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for arthrocentesis (20610) and methylprednisolone acetate (J1030) provided on March 19, 2019.
You asked the Plan to pay for the arthrocentesis and methylprednisolone acetate. You say that you would like reconsideration based on the record submitted. The Plan denied your request. The Plan says the submitted documentation does not support the services billed.
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 20610 is arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance. The CPT code Manual definition of code J1030 is injection, methylprednisolone acetate, 40 mg. We asked our coder 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 arthrocentesis and methylprednisolone acetate. Our reviewer says that the billing of CPT codes 20601 and J1030 is not supported by the record. Our reviewer found there is no documentation than an injection was actually provided.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the arthrocentesis and methylprednisolone acetate have not been met. Therefore, we decided that the Plan does not have to pay for arthrocentesis (20610) and methylprednisolone acetate (J1030) provided on March 19, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Magnetic Resonance Imaging (MRI) of the Lower Extremity Joint (73721) provided November 20, 2019 by Tower Imaging, LLC.You asked the Plan to waive the copayment for the MRI. You say that the copayment 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 MRI, MRA and Angiogram at a freestanding provider. You have been asked to pay a $100 copayment for an MRI furnished by a freestanding provider. 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 forMagnetic Resonance Imaging (MRI) of the Lower Extremity Joint (73721) provided November 20, 2019 by Tower Imaging, LLC.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve stereotactic body radiotherapy (SBRT).
You asked the Plan to pre-approve SBRT. You say that this is medically necessary. The Plan denied your request. The Plan says that this type of treatment is not supported for the enrollee's cancer.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. 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 SBRT. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the recent American Society for Radiation Oncology (ASTRO) model coverage policy states that SBRT for primary lung cancer (and for metastases to the lung) is considered medically necessary. The National Comprehensive Cancer Network (NCCN) guidelines also recognize SBRT as a standard of care procedure for stage T1-3N0 non-small cell lung cancer. It describes how SBRT is generally accepted to be superior to other forms of radiation therapy. This patient has undergone a thorough work-up to rule out nodal or distant metastases and appear to has either synchronous Stage I lung cancers, or a lung cancer with single oligometastasis, or a lung cancer and other lung nodule that may not be cancer though appears to be on imaging. SBRT for all of those scenarios falls within accepted standards of medical practice. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SBRT have been met. Therefore, we decided that the Plan has to pre-approve stereotactic body radiotherapy (SBRT).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You requested the orthotics on behalf of the enrollee. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of orthotics for their condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on September 30, 2019.You asked the Plan to pay for the orthosis. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.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 noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay fora knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on September 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve headrest (E0955) combination skin protection and
positioning seat (E2607) positioning wheelchair back cushion (E2620). You asked the Plan to pre-approve the wheelchair accessories. You say that the enrollee's policy replaces both Medicare and Medicaid therefore, it follows both guidelines and both insurance policy guidelines should be considered when reviewing. The Plan denied your request. The Plan says the requested items are not medically necessary and reasonable. The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 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 wheelchair accessories. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documented pressure ulcer or indication the claimant is unable to safely perform self-transfers. As such, these requests are convenience items and deemed not medically necessary. 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 wheelchair accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve headrest (E0955) combination skin protection and positioning seat (E2607) positioning wheelchair back cushion (E2620).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for initial hospital care (99223) provided October 22, 2019.
You asked the Plan to pay for initial hospital care. You say that the enrollee was already a patient in the hospital when the services were rendered. The Plan denied your request. The Plan says the billed initial hospital care service is inconsistent with the patient being in observation status.
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 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 initial hospital care. Our reviewer says that initial hospital care is not supported by the medical records. Our physician reviewer agrees that the billed initial hospital care service is inconsistent with the patient being in observation status. The review has determined that the records provided did not support that initial hospital care for the evaluation and management of a patient represented by CPT code 99223 were provided on the date of service in dispute. The review indicates that the enrollee underwent a history and physical for right hip pain, drainage from decubitus ulcer, fever and suicidal ideations. He was admitted to the medical floor and treated with IV antibiotics and a sitter at the bedside. An observation care discharge service, 99217, had been received and paid for the subsequent date of service. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of initial hospital care have not been met. Therefore, we decided that the Plan does not have to pay for initial hospital care (99223) provided October 22, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the Pride Victory LX Sport 4-Wheel purchased on April 15, 2019.
You asked the Plan to reimburse you for the scooter. You say that none of the in-network suppliers sell this scooter. The Plan denied your request. The Plan says the provider must be eligible to participate in Medicare.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items provided directly by a provider who is not eligible to take Medicare payment. The item at issue in this appeal was provided by a provider not certified by Medicare. Therefore, we decided that the Plan does not have to reimburse you for the Pride Victory LX Sport 4-Wheel purchased on April 15, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for colostomy supplies provided on November 27, 2019.
You asked the Plan to waive the coinsurance for the colostomy supplies. You say that you did not know there was cost-share. 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 colostomy supplies provided on November 27, 2019. You are asked to pay 20% coinsurance for the colostomy supplies. 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 colostomy supplies provided on November 27, 2019.
Appeal type: Practitioner Services
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 November 4, 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 to the enrollee by an out-of-network provider on November 4, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Canvas Ataxia Repeat Expansion Panel genetic test for the enrollee.
You asked the Plan to pre-approve the test. You say that this is medically necessary. The Plan denied your request. The Plan says the medical record must show how the testing will change the course of treatment.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 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 test. Our reviewer says that the services at issue in this case were not medically reasonable or necessary. Our physician reviewer found while the requested test may result in a definitive diagnosis for this enrollee, the diagnostic information would not result in a change in disease/symptom treatment or management. Therefore, the requested test is not currently shown to be medically necessary or reasonable. 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 test have not been met. Therefore, we decided that the Plan does not have to pre-approve the Canvas Ataxia Repeat Expansion Panel genetic test for the enrollee.