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

We decided that the Plan does not have to waive the copayment for the CT scan provided on June 20, 2019.
You asked the Plan to waive the copayment for the CT scan. You say that you were informed there was no copayment. 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 $150 copayment for each Medicare-covered advanced radiology service. You have been asked to pay a $150 copayment for the CT scan. The 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 June 20, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Injectafer infusions.
You asked the Plan to pre-approve the Injectafer infusions. You say that the requested Injectafer infusions are medically necessary. The Plan denied your request. The Plan says the enrollee has normal Hgb and a ferritin of 80. The Plan says that, at this time, there is no rationale to give IV iron.
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 the Injectafer infusions. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found a provider note dated November 21, 2019 states the enrollee has a history of total gastrectomy and intermittently requires iron transfusions. The documentation states the enrollee has not received an infusion in one year. The enrollee was noted to have normal hematocrit and hemoglobin. The documentation provided does not include iron studies or evidence to support anemia. Without the support of the documentation, medical necessity cannot be determined. 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 Injectafer infusions have not been met. Therefore, we decided that the Plan does not have to pre-approve Injectafer infusions.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for advanced life support (level 2) transportation services provided to the enrollee on August 23, 2019.
You asked the Plan to pay for the services. You say that the claim should be reprocessed for payment. The Plan denied your request. The Plan says none of the services meet the definition for advanced life support - level 2.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. In this case, the definition of the denied codes is: HCPCS A0433: advanced life support, level 2 HCPCS A0425: ground mileage per statute We asked our coding 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 services at issue in this case were not coded correctly. Our coding reviewer found there is no evidence that t he enrollee received multiple IV medications or advanced cardiac life support measures. Therefore, the billing of ALS2 services is not supported. 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 services have not been met. Therefore, we decided that the Plan does not have to pay for advanced life support (level 2) transportation services provided to the enrollee on August 23, 2019.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pre-approve radiation therapy.You asked the Plan to pre-approve radiation therapy. You say that the services are necessary.The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.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 radiation therapy. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found intensity modulated radiation therapy (IMRT) is not experimental, but rather a useful tool available to radiation oncologists to potentially reduce toxicity and improve the dose distribution in enrollees when the dose-volume exposure of normal tissues warrants its use. IMRT is necessary when the need is sufficiently supported. Justification for IMRT is provided in this case. As such, the need for IMRT is established and plausible.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of radiation therapy have been met.Therefore, we decided that the Plan has to pre-approveradiation therapy.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance ride provided on August 25, 2019.
You asked the Plan to waive the copayment for the ambulance ride. You say that you were not told that the patient would be responsible for the copayment for the emergency transfer service. You say you were not given a choice and told the hospital would handle the transfer and transport. 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $195 copayment per one-way trip for Medicare-covered ground ambulance services. The enrollee has been asked to pay a $195 copayment for the ambulance ride. The ambulance ride falls within the "Ambulance services" benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance ride provided on August 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthoses and suspension sleeves provided on September 17, 2019.
You asked the Plan to pay for the knee orthoses (L1851) and suspension sleeves (L2397). You say that the orthoses were medically necessary. The Plan denied your request. The Plan says criteria for the orthoses was not met.
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 knee orthoses (L1851) and suspension sleeves (L2397). Our physician reviewer found coverage of bilateral knee orthoses with suspension sleeves has been requested. At issue is whether the requested orthoses with sleeves were medically reasonable and necessary in this case, according to the coverage criteria established by the LCD. The documentation in the case file does not support that the requested knee orthoses with sleeves were medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. There is no documentation of recent injury to, or recent surgical procedure on, either of the enrollee's knees, and there is insufficient credible objective documentation of joint laxity. The item coded L2397 (sleeve) is not separately payable when the base item is not covered.
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 knee orthoses (L1851) and suspension sleeves (L2397) have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthoses and suspension sleeves provided on September 17, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on October 2, 2019.
You asked the Plan to waive the copayment for the ambulance transport. You say that you weren't given a choice of transport. You say that you are appealing the charge. 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 $265 copayment per date of service regardless of the number of trips for ground ambulance services. You have been asked to pay $256.83, which is less than the standard $265 copayment for the ambulance transport. The ambulance transport falls within the "Ambulance 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. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance transport provided on October 2, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Monovisc injections for the enrollee.
You asked the Plan to pre-approve Monovisc. You say that without the injections you will have serious knee pain. The Plan denied your request. The Plan says that the use of this medicine is not helpful in treating knee pain.
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 Monovisc. Our reviewer says that Monovisc is not medically reasonable and necessary for the enrollee in this case. Monovisc remains experimental for knee degenerative joint disease pain. Recent research shows that the injections are not better than sham treatment. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of Monovisc. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Monovisc have not been met. Therefore, we decided that the Plan does not have to pre-approve Monovisc injections for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided from February 15, 2019 to August 1, 2019.
You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that you were not informed that you would owe such a high coinsurance and 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). The enrollee's contract with the Plan clearly says that enrollees must pay 20% coinsurance for Medicare Part B prescription drugs. You received Medicare Part B drugs from February 15, 2019 to August 1, 2019. Therefore, you are responsible to pay your share of the cost-sharing charges. Please see the chart below.
Date of Service
Service
Allowed Amount
Amount You Owe
2/15/2019
Injections
$2,277.62
$446.39
7/2/2019
Injections
$2,277.80
$455.56
8/1/2019
Injections
$2,277.80
$455.56
The total amount you owe is: $1,357.51.
The enrollee has been asked to pay the total coinsurance amount of $1,357.51 for Medicare Part B drugs. Medicare Part B drugs fall within the Medicare Part B prescription drugs benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided from February 15, 2019 to August 1, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller, expandable controller harness and electronic connection for the enrollee.
You asked the Plan to pre-approve these items. The Plan denied your request. The Plan says that there is not a medical need to control these power options through the joystick because these power options can be controlled by own switches that are included in the allowance of these power options.
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 items. Our reviewer says that these items are not medically reasonable and necessary for the enrollee in this case. The documentation does not reveal that the patient requires a proportional input device, an attendant control, other electronic devices such as augmentative speech device, a separate display, a non proportional input device such as sip and puff, or the need to control three or more power seating actuators through the drive control. The patient's strength is sufficient to control the power options with their separate switches already included with the approval of these power options. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these items. 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 items have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller, expandable controller harness and electronic connection for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair electronic connection.
You asked the Plan to pre-approve power wheelchair electronic connection (E2310). You say that the enrollee needs the electronic connection to control the seat function with the joystick. The Plan denied your request. The Plan says the notes do not show a medical need to control the power option through the joystick.
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 power wheelchair electronic connection (E2310). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee does not meet the requirement for E2310 power wheelchair accessory, electronic connection between wheelchair controller and one power seating system motor, including all related electronics. The enrollee's strength and current functional ability is sufficient to control the power options (including power seating system tilt) with their separate switches already included with the approval of these power options. It is not medically necessary for the enrollee to have the electronic connection and control the power seating system tilt by joystick.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of power wheelchair electronic connection (E2310) have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair electronic connection (E2310).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT scan provided on October 22, 2019.
You asked the Plan to waive the copayment for the CT scan. You say that you have never had to pay a copayment for CT scans in the past. 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 $50 copayment for diagnostic radiological services (advanced imaging examples include but are not limited to MRI, CT scan and PET scan).
You have been asked to pay a $50 copayment for the CT scan. The 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 October 22, 2019.
Our decision is only about the October 22, 2019 services. If you have any questions about prior years billing, please contact the plan directly.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic mammogram or the ultrasound provided on August 26, 2019.
You asked the Plan to waive the copayment for the diagnostic mammogram and the ultrasound. You say that you were told there would be no charge for your mammogram and ultrasound. 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 $100 copayment for each in-network Medicare-covered radiological diagnostic service, not including x-rays, performed in a physician's office or at free-standing facility (such as a radiology center or medical clinic). You have been asked to pay a $100 copayment for the diagnostic mammogram and the ultrasound. The diagnostic mammogram and the ultrasound 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 the diagnostic mammogram or the ultrasound provided on August 26, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on August 17, 2019, by an out of network (OON) provider.You asked the Plan to pay forthe non-emergent ambulance services. You say that the transport was medically necessary.The Plandenied your request. The Plan says you did not request prior authorization for the transport.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 fromout-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 forthe ambulance services provided on August 17, 2019,by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the shoulder elbow wrist hand orthosis provided on August 6, 2019.
You asked the Plan to pay for the shoulder elbow wrist hand orthosis (L3960). You say that the orthosis was medically necessary. The Plan denied your request. The Plan says the documentation submitted demonstrated no complaints, examinations, diagnoses, treatment, or issues with the right shoulder.
The Plan must follow Medicare rules. The records do not support medical necessity of the orthosis. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the shoulder elbow wrist hand orthosis (L3960) have not been met. Therefore, we decided that the Plan does not have to pay for the shoulder elbow wrist hand orthosis provided on August 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis and the wrist hand orthosis provided on October 14, 2019.
You asked the Plan to pay for the lumbar-sacral orthosis (L0650) and the wrist hand orthosis (L3916). You say that the orthoses were medically necessary. The Plan denied your request. The Plan says rules for telehealth services were not met.
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 for the lumbar-sacral orthosis and the wrist hand orthosis provided on October 14, 2019.