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

We decided that the Plan does not have to pay for chemotherapy administration (96413, 96417, 96411 and 96415) and a therapeutic injection (96375) provided on September 17, 2019.You asked the Plan to pay for the chemotherapy administration and therapeutic injection. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the medical records do 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 96413 is chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug.The CPT Code Manual definition of code 96417 is chemotherapy administration, intravenous infusion technique; each additional sequential infusion (different substance/drug), up to 1 hour (List separately in addition to code for primary procedure).The CPT Code Manual 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).The CPT Code Manual definition of code 96411 is chemotherapy administration; intravenous, push technique, each additional substance/drug (List separately in addition to code for primary procedure).The CPT Code Manual definition of code 96415 is chemotherapy administration, intravenous infusion technique; each additional hour (List separately in addition to code for primary procedure).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 chemotherapy administration and therapeutic injection. Our reviewer says that CPT codes 96413, 96417, 96375, 96411 and 96415 do not meet criteria for billing or reimbursement consideration. The record submitted does not include documentation to validate the total time for which the drugs were given. Our reviewer found CPT codes 96417, 96375, 96411 and 96415 are add-on codes that require the primary code, 96413, to be eligible for reimbursement before they can be eligible.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 chemotherapy administration and therapeutic injection have not been met.Therefore, we decided that the Plan does not have to pay for chemotherapy administration (96413, 96417, 96411 and 96415) and a therapeutic injection (96375) provided on September 17, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided from October 9, 2019 to October10, 2019.You asked the Plan to pay for these drugs. You say that all the medicines were given to you from the hospital and were not self-administered.The Plan denied your request. The Plan says that these are not 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 pay for the self-administered drugs provided from October 9, 2019 to October 10, 2019.Benefits for these 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the inpatient hospital stay provided from
November 26, 2018 to December 2, 2018.
You asked the Plan to reduce the copayment for the inpatient hospital stay. You say that you do not think you
should owe so much money. You say you were ready to be discharged on November 30, 2019 and should not
be charged the extra days. The Plan denied your request. The Plan says you have been charged the correct cost
sharing 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 $225
copayment per day, per admission for days 1-5 and a $0 copayment per day, per admission for days 6-90.
You have been asked to pay a $225 copayment for each day, days 1-5 of the inpatient hospital stay. ($225 x 5 =
$1,125). The inpatient hospital stay falls within the "Inpatient hospital care" benefit category. The medical
record shows you were discharged on December 2, 2018.
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 reduce the copayment for the inpatient hospital stay provided from November 26,
2018 to December 2, 2018.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory tests provided on November 8, 2019.You asked the Plan to waive the copayment for laboratory tests. 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 $20 copayment for laboratory tests. You have been asked to pay a $20 copayment for laboratory tests. Laboratory tests fall within the outpatient diagnostic tests and therapeutic services and supplies 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 laboratory tests provided on November 8, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the digital breast tomosynthesis rendered to the enrollee on
December 4, 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 code 77061 is not covered.
The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid
for Medicare purposes.
We looked at the file and Medicare rules. The provider submitted a claim for procedure code 77061. This code
has a status indicator of I and is not valid for Medicare purposes. Therefore, we decided that the Plan does not
have to pay for the digital breast tomosynthesis rendered to the enrollee on December 4, 2019.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Nusinersen for the enrollee.
You asked the Plan to pre-approve Nusinersen. You say that this is medically necessary. The Plan denied your request. The Plan says that that criteria are not met for Nusinersen.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Nusinersen. Our reviewer says that that Nusinersen is medically reasonable and necessary for the enrollee in this case. The patient has a diagnosis of spinal muscular atrophy. The requested drug is FDA approved for use in the patient's condition. The FDA approved the drug for use in patients of any age. There is otherwise no limitation on administration of the drug in patients who have undergone trach placement. The patient has received this medication in the past without complication. Our physician reviewer found that the enrollee's condition meets criteria for coverage of Nusinersen. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Nusinersen have been met. Therefore, we decided that the Plan has to pre-approve Nusinersen for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services provided on September 19, 2019 by an out
of network (OON) provider.
You asked the Plan to pay for radiology services. You say that you would like this claim reprocessed and
approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained. The
Plan says that there are in-network providers within 30 miles of the member's residence that could have
provided 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 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 radiology services provided on September 19,
2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial upper denture (D5213) and a partial lower denture (D5214).
You asked the Plan to pre-approve the dental services. You say that your previous dentist provided horrible dentures. You say that you took the dentures back. You say that the dentist made another mold. You say that you were not satisfied with this. You also say that the dentist advised if you give the teeth back, she would refund the money to your insurance. The Plan denied your request. The Plan says the frequency limit for dentures has been reached.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage and partial dentures are a covered service, the frequency limit has been reached. The record shows the Plan paid for dentures that you received on August 8, 2019. Therefore, we decided that the Plan does not have to pre-approve a partial upper denture (D5213) and a partial lower denture (D5214).
Your complaint about the services you received from your previous dentist is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on May 22, 2019 by an out of network (OON) provider.You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.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 laboratory services provided on May 22, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are available from network providers.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral to an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a spinal canal injection provided on September 4, 2019.
You asked the Plan to waive the copayment for a spinal canal 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 $250 copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers. You have been asked to pay a $250 copayment for a spinal canal injection. A spinal canal injection falls within the outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers 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 spinal canal injection provided on September 4, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213) and a mandibular partial denture (D5214).
You asked the Plan to pre-approve the maxillary and mandibular partial dentures. You say that you have poor quality teeth and you are unable to eat in a healthy manner. The Plan denied your request. The Plan says these services are not covered benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture (D5213) and a mandibular partial denture (D5214).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from May 21, 2019 through May 28, 2019.
You asked the Plan to waive the copayment for the inpatient stay. You say that you were only admitted to one hospital. You say that you are being charged for two admissions instead of one. The Plan denied your request. The Plan says the copayment 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 a $360 copayment per day, per admission for days 1-5 and a $0 copayment per, day per admission for days 6-90 for in-network covered hospital stays. Inpatient hospital care starts the day you are formally admitted to the hospital with a doctor's order. The day before you are discharged is your last inpatient day. You have been asked to pay a $1,800 copayment for the inpatient stay. ($360/day x first 5 days = $1,800). The inpatient stay falls within the "Inpatient Hospital 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 for the inpatient stay provided from May 21, 2019 through May 28, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower denture (D5120).
You asked the Plan to pre-approve the dental items. You say that you have type 2 diabetes and heart problems. You say that you need new dentures in order to eat and get the right nutrition to stay healthy. The Plan denied your request. The Plan says dentures are not a covered service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, dentures are not among those covered under this benefit. The record also shows that dentures are not covered under your 2020 dental plan either. Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower denture (D5120).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 3, 2019 to the enrollee by a non-participating provider.
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 the services were rendered by a non-participating provider without prior authorization.
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 medical services provided on December 3, 2019 to the enrollee by a non-participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network vascular specialist for the enrollee.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are available from network providers.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral to an out-of-network vascular specialist for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT scan provided on August 7, 2019.You asked the Plan to waive the copayment for the CT scan. You say that you don't understand why insurance didn't pay anything.The Plan denied your request. The Plan says the copayment 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 a $225 copayment for services performed by a provider other than your primary care physician.You have been asked to pay$141.14 for the CT scan. Service Allowed Amount Standard Copayment Member Liability CT Scan$141.14$225$141.14The CT scan falls within the "Outpatient diagnostic tests and therapeutic services and supplies" 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 the CT scan provided on August 7, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transcutaneous electrical nerve stimulation (TENS) device.
You asked the Plan to pre-approve a TENS device. You say that you need a TENS device for your pain. The Plan denied your request. The Plan says your provider did not provide the length of time you have tried this therapy.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. There is no documentation of a clinical study. Based on this information, we decided that Medicare rules for coverage of a TENS device have not been met. Therefore, we decided that the Plan does not have to pre-approve a transcutaneous electrical nerve stimulation (TENS) device.