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

We decided that the Plan does not have to waive the cost share for the daratumumab injection, chemotherapy administration and therapeutic injection provided on January 24, 2020.
You asked the Plan to waive the cost share for the daratumumab injection, chemotherapy administration and therapeutic injection. You say that you never had a copayment or deductible for over ten years. You say that if the hospital billed properly you wouldn't have a copayment balance. 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 20% coinsurance for each Medicare-covered chemotherapy drug and the administration of that drug and a $75 copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges. You have been asked to pay a total of $1,249.53 for the daratumumab injection, chemotherapy administration and therapeutic injection. The daratumumab injection and chemotherapy administration fall within the "Medicare Part B Prescription Drugs" benefit category. The therapeutic 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 cost share for the daratumumab injection, chemotherapy administration and therapeutic injection provided on January 24, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for Percepta bronchial genomic classifier testing provided on April 21, 2020.
You asked the Plan to pay for laboratory test. You say that this testing is covered by Medicare and enabled the enrollee's treating physician to move forward with determining the most safe and effective course of treatment. The Plan denied your request. The Plan says that the denial of payment for this service is correct, because this test does not meet the Medicare criteria for coverage.
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. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not specify whether the ordering physician was in-network or out-of-network with the Plan at the time the lab order was made. The documentation submitted does not include prior notice from the Plan that this testing would not be covered. This testing is not fully excluded from Medicare coverage and may be covered under some conditions. Without this information, we cannot determine whether the lab order made constituted plan-directed care. Therefore, the Plan has not shown that its decision to deny payment is correct or justified by Medicare rules. Therefore, we decided that the Plan has to pay for Percepta bronchial genomic classifier testing provided on April 21, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible foran X-ray provided on June 26, 2020.You asked the Plan to waive the deductible foran X-ray. You say that you cannot afford 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. Your contract with the Plan says that there is a $750 deductible for outpatient diagnostic tests and therapeutic services and supplies. You received an X-ray on June 26, 2020. The record shows that you had paid $0 toward the $750 deductible prior to receiving the services. Therefore, you are responsible to pay $71.95. The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible for outpatient diagnostic tests and therapeutic services and supplies. This cost sharing is a contractual obligation that had not been met at the time an X-ray was received on June 26, 2020.Therefore, we decided that the Plan does not have to waive the deductible foran X-ray provided on June 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe subsequent hospital care services coded 99231 provided on July 15, 2020.You asked the Plan to pay forthe subsequent hospital care services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not separately payable.The Plan must follow Medicare rules. Medicare rules say that providers must reportservices correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 99231 is subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A problem focused interval history; A problem focused examination; Medical decision making that is straightforward or of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is stable, recovering or improving. Typically, 15 minutes are spent at the bedside and on the patient's hospitalfloor or unit.We find that CPT code 99231 is not supported in the medical record. Specifically, this service was part of the global surgical package of major procedure code, 47562 (Laparoscopy) billed on July 6, 2020. The provider of the service at issue and the laparoscopy services were provided by the same primary specialty and are from the same group. These providers are considered the same provider. Therefore, the services at issue are included in the global surgical package and are not separately payable. Based on this information, we decided that Medicare rules for coverage of the subsequent hospital care services have not been met.Therefore, we decided that the Plan does not have to pay forthe subsequent hospital care services coded 99231 provided on July 15, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forx-rays provided by a chiropractor on August 3, 2020.You asked the Plan to payforthe x-rays provided by a chiropractor. You say that the Plan has paid for x-rays in the past. You say that the x-rays are to check your spine and metal in your face. You say that you would think the Plan would help with your care.The Plan denied your request. The Plan says the services in dispute would not be covered under any circumstances. The Plan says that chiropractic benefits are limited, and x-rays are excluded.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the services at issue are not manual manipulation of the spine.Therefore, we decided that the Plan does not have to pay forx-rays provided by a chiropractor on August 3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for screening cytopathology services provided on September 9, 2020 by an out of network (OON) provider.
You asked the Plan to pay for screening cytopathology services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained.
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 screening cytopathology services provided on September 9, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment forthe eye exam provided on August 12, 2020.You asked the Plan to reduce the copayment forthe eye exam. You say that the copayment for the exam should have been $20.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 $50 copayment for Medicare covered vision services at an in-network specialist's office.You have been asked to pay a $50 copayment for the eye exam. The eye exam falls within the "Vision 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 reduce the copayment forthe eye exam provided on August 12, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient rehabilitation stay from December 17, 2019, to December 23, 2019.
You asked the Plan to waive the copayment for an inpatient rehabilitation stay. You say that the facility you normally go to was not approved so you had to go to another facility and now you owe 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 $350 copayment for days 1-5 for an inpatient hospital care. The medical records show that you had an inpatient rehabilitation stay from December 17, 2019, to December 23, 2019. Therefore, you are you are responsible to pay a $350 copayment for days 1-5 (December 17, 2019, to December 21, 2019). $350 (copayment) x 5 (inpatient days) = $1,750. You have been asked to pay the total copayment amount of $1,750 for an inpatient rehabilitation stay. An inpatient rehabilitation stay falls within the an 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 an inpatient rehabilitation stay from December 17, 2019, to December 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for injections (96374) provided from May 27, 2020, to June 3,
2020.
You asked the Plan to pay for injections. You say that this should be covered. The Plan denied your request.
The Plan says documentation has not been received to show this was billed correctly.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. The rules also say that the provider, supplier, or
beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine
whether payment is due and the amount of payment.
We find that CPT code 96374 is not supported in the medical record. Specifically, no medical records for this
service have been submitted. Based on this information, we decided that Medicare rules for coverage of
injections have not been met. Therefore, we decided that the Plan does not have to pay for injections (96374)
provided from May 27, 2020, to June 3, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvehome health skilled nursing services for the enrollee.You asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is not medically necessary for urine incontinence.The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.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 services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found based on the medical records provided there is no documentation that skilled nursing services are required to effectively provide treatment, care, and/or services in orderto improve the enrollee's condition, or to establish/perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration. Home health nursing is being requested for phlebotomy service in the home; there is no documentation in the records of a skilled nursing need.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plandoes not haveto pre-approvehome health skilled nursing services for the enrollee
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve magnetic resonance imaging, (MRI) spinal canal and contents (72148).
You asked the Plan to pre-approve MRI. You say that the claim was denied for lack of supporting information. You received the correct information and have attached for appeal. Please review. The Plan denied your request. The Plan says that services requested do not meet medical necessity criteria.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 MRI. Our reviewer says that the requested items/services is considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee with severe lower back pain, radicular in nature. The severity and radiating nature of pain make the MRI indicated of his spine. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of MRI have been met. Therefore, we decided that the Plan has to pre-approve magnetic resonance imaging, (MRI) spinal canal and contents (72148).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe custom fabricated abutment (D6057) and abutment supported porcelain/ceramic crown (D6058) provided on June 4, 2020.You asked the Plan to pay forthe custom fabricated abutment and abutment supported porcelain/ceramic crown. You say that the care you received was medically necessary.The Plan denied your request. The Plan says the services in question are not a covered benefit.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 pay forthe custom fabricated abutment (D6057) and abutment supported porcelain/ceramic crown (D6058) provided on June 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecontinuous positive airway pressure (CPAP) device and humidifier.You asked the Plan to pre-approvecontinuous positive airway pressure device and humidifier. You say that you would like the plan to reconsider their denial.The Plandenied your request. The Plan says the requested items are not medically necessary.The Plan follows Medicare rules. Medicare rules say that continued use of CPAP is only covered for certain indications.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 continuous airway pressure device and humidifier. Our reviewer says that the requested devices are not medically necessary. Our physician reviewer found the compliance report from July 23, 2020 to August 21, 2020 you used at least 4 hours for 37% of the days. Coverage criteria for continued use of Continuous Positive Airway Pressure (CPAP) are not met. Compliance reports do notmeet the minimum use requirement of at least 70% of days with at least 4 hrs/day. You are not using the device enough to be beneficial. There is no recent clinical visit to address usage issues. Therefore, you do not meet criteria for the requested 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 continuous positive airway pressure device and humidifier have not been met.Therefore, we decided that the Plan does not have to pre-approvecontinuous positive airway pressure (CPAP) device and humidifier.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug provided on August 4, 2020.
You asked the Plan to waive the coinsurance for a Medicare Part B drug. You say that you already paid the $50 copayment and disagree with the additional 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 20% coinsurance for Medicare Part B prescription drugs. You received a Medicare Part B drug on August 4, 2020. The allowed amount is $449.40 and 20% of that is $89.88. You have been asked to pay the total coinsurance amount of $89.88 for a Medicare Part B drug. 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 coinsurance for a Medicare Part B drug provided on August 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on August 11, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe medical services. You say that these services were provided in good faith.The Plan denied your request. The Plan says unauthorized, non-plan care is 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 provider in this case is not a network provider with the Plan. 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 payforthe medical services provided on August 11, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean interspinous spacer device.You asked the Plan to pre-approvethe requested services. You say that the enrollee is not a candidate for a larger lumbar fusion given her co-morbidities.The Plan denied your request. The Plan says the service is considered experimental and investigational.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 requested services. Our physician reviewer found the interspinous spacer is indicated to treat skeletally mature patients suffering from pain, numbness, and/or cramping in the legs,secondary to a diagnosis of moderate degenerative lumbar spinal stenosis, confirmed by imaging evidence. It is alsoindicated for those with impaired physical function who experience relief in flexion from symptoms of leg/buttock/groin pain, who have undergone at least 6 months of non-operative treatment. This enrollee presents with a 3-year history of low back and buttock pain. Symptoms are reported consistent with neurogenic claudication. There is imaging evidence of ligamentum flavum thickening at L3/4 and L4/5 with minimal thecal sac attenuation and minimal left L4/5 neuroforaminal narrowing. It was documented that she was not indicated for standard decompression as her pathology was not severe. She has reportedly failed long-term conservative treatment. Current evidence based medical guideline and peer reviewed literature do not fully support the spinal decompression device procedure over the standard of lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studiesto support the use of this device for this enrollee's medical condition. Therefore, the requested device is notmedically reasonable and necessary for treatment of this enrollee's medical condition. 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 requested services have not been met.Therefore, we decided that the Plan does not have to pre-approvean interspinous spacer device.