Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for portable oxygen contents, gaseous, 1 month's supply = 1 unit (CPT Code E0443) provided from July 21, 2019 through September 21, 2019.
You asked the Plan to waive the coinsurance for the DME. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received portable oxygen contents from July 21, 2019 through September 21, 2019. You are asked to pay 20% coinsurance per date of service for the DME. 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 portable oxygen contents, gaseous, 1 month's supply = 1 unit (CPT Code E0443) provided from July 21, 2019 through September 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee on February 4, 2019.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for 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 medical services provided to the enrollee on February 4, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on September 23, 2019.
You asked the Plan to pay for the ambulance services. You say that transport by stretcher was medically necessary. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when they meet certain origin and destination requirements. A doctor's office is not a covered destination. The services you have asked the Plan to pay for are ambulance transport services to a doctor's office. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on September 23, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for continued skilled nursing facility (SNF) services provided April 8, 2019 to April 23, 2019.
You asked the Plan to pay for the SNF services. You say that you feel that the plan should cover for the SNF services. The Plan denied your request. The Plan says the Medicare criteria for continued SNF level of coverage were not met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 pay for the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing and skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis and does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.
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 SNF services have not been met. Therefore, we decided that the Plan does not have to pay for continued skilled nursing facility (SNF) services provided April 8, 2019 to April 23, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from August 3, 2019 through August 6, 2019.
You asked the Plan to waive the copayment for the inpatient stay. You say that you were informed there would be no cost for this visit. 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 $300 copayment a day for days 1-5 for each inpatient admission. 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 $900 copayment for the inpatient stay. ($300/day x 3 days = $900). 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 August 3, 2019 through August 6, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hydroxyzine Pam for the enrollee.You asked the Plan to pre-approve Hydroxyzine Pam under Medicare Part B. You say that this drug is medically necessary.The Plan denied your request. The Plan says this drug is not covered under Medicare Part B.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approve Hydroxyzine Pam for the enrollee.Benefits for Hydroxyzine Pam under Medicare Part B may be available under Medicare Part D.Contact the Plan that administers the enrollee's Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued use of a bi-level respiratory assist device for the enrollee.
You asked the Plan to pre-approve continued bi-level respiratory assist device use. You say that the enrollee has been counseled about compliance. The Plan denied your request. The Plan says that the enrollee has not met compliance requirements.
The Plan must follow Medicare rules. Medicare rules say that you must use the PAP 4 hours per night on 70% of nights during a consecutive thirty (30) day period anytime during the first three (3) months of initial usage. We looked at the file and Medicare rules. The compliance report included with the file indicates the enrollee did not adhere to therapy. Based on this information, we decided that Medicare rules for coverage of continued bi-level respiratory assist device use have not been met. Therefore, we decided that the Plan does not have to pre-approve continued use of a bi-level respiratory assist device for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea pneumatic compression device (E0652) and sleeves (E0667).You asked the Plan to pre-approvea pneumatic compression device and sleeves. You say that this is medically necessary.The Plan denied your request. The Plan says that your medical record shows that you have not had a four week trial of an E0650 or E0651.The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment withan E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not beenmet. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.Therefore, we decided that the Plan does not have to pre-approvea pneumatic compression device (E0652) and sleeves (E0667).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pay fora wellness exam received on September 26, 2019.You asked the Planto pay forthe exam. You say that you should not be liable, as you were not aware that this was only covered once per year.The Plandenied your request. The Plansaysthis is only covered once every 12 months.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 annual wellness exams can only be covered once per year.The file shows that an annual wellness exam was received on March 26, 2019. This is the only exam that can be covered this year.Therefore, we decided that the Plandoes not haveto pay fora wellness exam received on September 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Orcam My Eye Device.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit, as it is not for a primarily medical purpose.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve the Orcam My Eye Device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided to the enrollee from January 15, 2019 through January 19, 2019 by an in-network provider.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you are appealing the member's cost-share responsibility for the services the member received. The Plan denied your request. The Plan says the claim was processed accordingly with the member's 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file shows that the enrollee was admitted to an in-network provider on January 15, 2019 and discharged on January 19, 2019. The enrollee is asked to pay a $200 copayment per day from January 15, 2019 through January 18, 2019, days 1-4 of their inpatient hospital care. The enrollee was discharged on January 19, 2019 and there was no copayment charge for the day of discharge. Per your contract there is a $200 copayment per day required for days 1-4. 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 inpatient hospital care provided to the enrollee from January 15, 2019 through January 19, 2019 by an in-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xifaxan tablets.
You asked the Plan to pre-approve self-administered drugs. You say that you are appealing based on medical necessity. 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 also says that the enrollee's Medicare Part D prescription drug benefits may be administered by Express Scripts.
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 Xifaxan tablets.
Benefits for self-administered 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacroiliac joint radiofrequency ablation for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says research has not proven that any method of ablation for SI joint pain is helpful.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found radiofrequency facet joint denervation of spinal nerves in the treatment of sacroiliac joint pain is considered experimental/investigational. The safety and/or effectiveness of this procedure cannot be established by review of the available published peer-reviewed literature. Larger, well-designed trials are needed for comparing specific procedures in defined populations for use in sacroiliac pain and to determine the potential candidates and treatment parameters for this disorder. In this case, the enrollee has lumbar facet arthropathy and diagnostic medial branch blocks could be performed targeting the lumbar spine. An alternative treatment might be a lumbar radiofrequency ablation. 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 Plan does not have to pre-approve sacroiliac joint radiofrequency ablation for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the inhalation of nitrous oxide (D9230) provided on September 18, 2019.
You asked the Plan to pay for the dental service. You say that you require nitrous gas whenever needs are needed due to a bad experience when you were younger. You say that you cannot afford the amount you are being charged. You also say that you were not aware that your insurance does not cover this service. The Plan denied your request. The Plan says the inhalation of nitrous oxide 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, the inhalation of nitrous oxide is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the inhalation of nitrous oxide (D9230) provided on September 18, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on September 4, 2019.
You asked the Plan to pay for the laboratory services. 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 laboratory services. 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 services provided on September 4, 2019.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve rituximab injections.
You asked the Plan to pre-approve rituximab. You say that the enrollee has failed other medications, and a sarcoidosis expert recommended rituximab based on recently published literature. The Plan denied your request. The Plan says that the denial of authorization for this drug is correct, because rituximab is not supported for the enrollee's condition.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 rituximab. Our reviewer says that the enrollee meets the Medicare criteria for rituximab injections. Our physician reviewer found the enrollee has uncontrolled sarcoidosis involving the bone and lungs that has failed conventional therapy. The enrollee has progressed beyond standard therapy with other medications such as prednisone and methotrexate. There is literature to support the use of rituximab which would be a potentially safe and effective alternative for this enrollee. Therefore, this service is medically reasonable and necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of rituximab have been met. Therefore, we decided that the Plan has to pre-approve rituximab injections.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee and billed under
codes 99152 and 99153.
You asked the Plan to pay for this claim. You say that this claim should be paid. The Plan denied your request.
The Plan says code 99152 is not supported by the medical records based on the timing documentation
requirements for this code. The Plan says code 99153 is included in the payment to the facility and is not
separately reimbursable.
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, codes 99152 and 99153 cannot be paid as billed due to either insufficient time documentation or
because it is bundled into the payment of a facility claim. Based on this information, we decided that Medicare
rules for coverage of this claim have not been met. Therefore, we decided that the Plan does not have to pay for
physician services provided to the enrollee and billed under codes 99152 and 99153.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for an Electrocardiogram (ECG) reading (93042) provided June
3, 2019.
You asked the Plan to pay for the ECG reading. You say that the services at issue were medically necessary.
The Plan denied your request. The Plan says the record does not show that the ECG reading was a service
separate from the ER Physician services already 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.
We find that CPT code 93042 is not supported in the medical record. Specifically, the reporting of code 93042
is intended to represent a formal interpretation and subsequent report of the ECG findings. A professional
component billing based on a review of the findings of these procedures, without a complete, written report
similar to that which would be prepared by a specialist in the field, does not meet the conditions for separate
payment of the service. Payment for a brief ECG interpretation would be included in the Emergency Room
Visit (99285) already paid. Based on this information, we decided that Medicare rules for coverage of the ECG
reading have not been met. Therefore, we decided that the Plan does not have to pay for an Electrocardiogram
(ECG) reading (93042) provided June 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the $45 copayment charged for a specialist visit provided on September 12, 2019.
You asked the Plan to waive this copayment. You say that you do not believe this copayment is correct. The Plan denied your request. The Plan says this copayment was charged based on the services provided and the Plan contract agreement.
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 $45 copayment for specialist services. You have been asked to pay $45 copayment for this copayment. this copayment falls within the specialist 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 $45 copayment charged for a specialist visit provided on September 12, 2019.