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

We decided that the Plan does not have to waive the copayment for laboratory tests provided on January 24,
2020 and February 3, 2020.
You asked the Plan to waive the copayment for laboratory tests. You say that you don't understand why these
charges aren't considered authorized visits. You say that you are owed a rebate. The Plan denied your request.
The Plan says the copayments 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 $40
copayment for lab services at an in-network outpatient hospital.
You have been asked to pay a $40 copayment for each visit for laboratory tests. The total amount you owe is
$80 ($40/visit x 2 visits = $80). The laboratory tests fall within the "Outpatient diagnostic tests and therapeutic
services and supplies" benefit category. The records show the claims processed in-network.
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 January 24, 2020 and February
3, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve onabotulinumtoxinA (J0585).
You asked the Plan to pre-approve onabotulinumtoxinA. You say that this drug has been used to successfully
treat the enrollee's condition. The Plan denied your request. The Plan says this drug is not supported for the
enrollee's diagnosis.
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 onabotulinumtoxinA. Our reviewer
says that the criteria for coverage of onabotulinumtoxinA has not been met. Our physician reviewer found the
enrollee is noted to have scleroderma and Raynaud's phenomenon. There is no evidence that the enrollee has
spasticity, achalasia, migraines or anal fissures. Therefore, the enrollee is not shown to have a medically
accepted indication for the use of the requested drug.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of onabotulinumtoxinA have not been met. Therefore, we decided that the Plan
does not have to pre-approve onabotulinumtoxinA (J0585).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital discharge day management services (99238)
provided on December 29, 2019.
You asked the Plan to pay for the hospital discharge day management services. You say that you would like
reconsideration based on the records submitted. The Plan denied your request. The Plan says the submitted
documentation supports one unit of hospital discharge day management, which was previously approved and
paid.
The Plan must follow Medicare rules. Medicare rules say that only one hospital discharge day management
service is payable per patient per hospital stay.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the hospital discharge day management services have not been met. Specifically, the record
indicates that one hospital discharge day management service has been previously approved for this provider
on this date of service. Therefore, we decided that the Plan does not have to pay for hospital discharge day
management services (99238) provided on December 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for thrombectomy services (37187) provided on February 6,
2020.
You asked the Plan to pay for the thrombectomy services. You say that you would like reconsideration because
this service was denied as a duplicate in error. The Plan denied your request. The Plan says the submitted
documentation supports one unit of CPT code 37187, which was approved and previously paid.
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined
to be exact duplicates of another claim or claim line are denied.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the thrombectomy services have not been met. Specifically, the record supports one unit of CPT
code 37187 was rendered. This service was approved and previously paid and the documentation submitted
does not indicate that additional services were rendered. Therefore, we decided that the Plan does not have to
pay for thrombectomy services (37187) provided on February 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an outpatient visit provided on February 7, 2020 by an out of
network (OON) provider.
You asked the Plan to pay for an outpatient visit. 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 the member's primary care physician did not refer 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 an outpatient visit provided on February 7, 2020
by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on February 18,
2020.
You asked the Plan to waive the copayment for the office visit. You say that there was no reason for the
appointment. You say that you are requesting a refund. 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 $30
copayment for each specialist visit for Medicare-covered benefits.
You have been asked to pay a $30 copayment for the office visit. The office visit falls within the
"Physician/Practitioner services, including doctor's office visits" benefit category. The records show that
services were provided during the follow up visit. 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 office visit provided on February 18, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic mammogram and ultrasound
provided on December 19, 2019.
You asked the Plan to waive the copayment for a diagnostic mammogram and ultrasound. You say that this
was a mammogram screening and 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 $100
copayment for each diagnostic procedure and test provided in an outpatient hospital facility.
You received a mammogram on December 19, 2019 at an outpatient hospital facility. Due to a personal history
of breast cancer, the mammogram is considered diagnostic, not preventative. Therefore, you are responsible to
pay the $100 copayment.
You have been asked to pay a $100 copayment for a diagnostic mammogram and ultrasound. A diagnostic
mammogram and 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 a diagnostic mammogram and
ultrasound provided on December 19, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the requested LTACH care is medically
reasonable and necessary. The Plan denied your request. The Plan says the requested LTACH care is not
considered medically reasonable and necessary in this case.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
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 LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee was admitted to acute care on 5/22/20 for treatment of small bowel
obstruction and acute respiratory distress syndrome.
Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not
provide clinical services that are materially different than those of short term acute care hospitals. In this case,
ongoing care needs include respiratory care with ventilator management and tracheostomy care, neurologic
monitoring, surveillance laboratory studies, tube feedings, wound care, and therapy services. The
documentation does not support that the enrollee in this case requires services at the LTACH that are not
available at the acute care hospital where he is currently receiving care. There are no required medical services
identified that are available at the LTACH, that are not available at the current health care setting being offered
by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and
appropriate for the diagnosis and condition of the enrollee at this time.
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 LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray services coded 71045 provided on January 26, 2020.
You asked the Plan to pay for the x-ray 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 a duplicate.
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 71045 is radiologic examination, chest; single view. We find that CPT code 71045 is not supported in the medical record. Specifically, the documentation shows that a claim was previously processed with the same subscriber/member number, dependent number, date of service, procedure code, provider Tax Identification number, units, physician specialty and procedure code modifier. Therefore, this code is a duplicate and cannot be separately paid. Based on this information, we decided that Medicare rules for coverage of the x-ray services have not been met. Therefore, we decided that the Plan does not have to pay for the x-ray services coded 71045 provided on January 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the wound care services provided from December 5, 2019 to December 19, 2019.
You asked the Plan to waive the copayments for the wound care services. You say that you do not agree with these charges. You say you have never been charged 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 $100 copayment for each covered surgery services in an outpatient hospital. You have been asked to pay a $100 copayment for each of the wound care services. The wound care services fall within the "Outpatient hospital 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 copayments for the wound care services provided from December 5, 2019 to December 19, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a hip injection provided on January 2, 2020.
You asked the Plan to waive the copayment for a hip injection. You say that you should only owe a $275 copayment for an MRI. 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 $345 copayment for surgery services provided in an outpatient hospital facility. You have been asked to pay a $345 copayment for a hip injection. A hip injection falls within the outpatient surgery, including 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 hip injection provided on January 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an aminophyllin injection (J0280) provided on December 10,
2019.
You asked the Plan to pay for the aminophyllin injection. You say that you would like reconsideration based on
the records submitted. The Plan denied your request. The Plan says the documentation submitted does not
support the units 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 J0280x3 is injection, aminophyllin, up to 250 mg.
We find that CPT code J0280x3 is not supported in the record. Specifically, the documentation submitted
indicates that 75mg of aminophyllin was given. One unit of CPT code J0280 is up to 250mg, therefore only one
unit is supported. Based on this information, we decided that Medicare rules for coverage of the aminophyllin
injection have not been met. Therefore, we decided that the Plan does not have to pay for an aminophyllin
injection (J0280) provided on December 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on February 1, 2019 by an out of network (OON) provider.
You asked the Plan to pay for physician 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.
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 physician services provided on February 1, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on December 27, 2019 by an out of network (OON) provider. You asked the Plan to pay for physician services. You say that these services were referred by the member's primary care physician. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the member's information should have been verified for eligibility. 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 physician services provided on December 27, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Emgality pens.
You asked the Plan to pre-approve self-administered drugs. You say that you are appealing. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Emgality pens.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory test provided on February 27, 2020.
You asked the Plan to waive the copayment for the laboratory test. You say that this was for a diabetes screening. You say that you shouldn't be charged. 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 $20 copayment per visit for laboratory tests. You have been asked to pay $8.74, which is less than the standard $20 copayment for the laboratory test. The laboratory test falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The laboratory test is considered a diagnostic test. 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 laboratory test provided on February 27, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on June 5, 2019.
You asked the Plan to pay for the laboratory testing. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 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 laboratory testing provided on June 5, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the vision exam and eyewear provided on February 17, 2020.
You asked the Plan to pay for the vision exam and eyewear. The Plan denied your request. The Plan says that the contract does not allow coverage for frames and lenses with an out-of-network provider.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when you use a Plan provider. We looked at the file and the Plan's rules. The file indicates these services were not received from a Plan provider. Based on this information, we decided that the Plan's rules for coverage of the vision exam and eyewear have not been met. Therefore, we decided that the Plan does not have to pay for the vision exam and eyewear provided on February 17, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Inflectra.
You asked the Plan to pre-approve Inflectra. You say that you want the enrollee to be treated with Inflectra. The Plan denied your request. The Plan says the enrollee has not first tried and had a contraindication or intolerance to Renflexis.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Inflectra. Our reviewer says that the criteria for step therapy has not been met. Our physician reviewer found there is no documentation of trial and failure of Renflexis. The documentation does not support that Renflexis (Infliximab-abda) would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Inflectra have not been met. Therefore, we decided that the Plan does not have to pre-approve Inflectra.