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

We decided that the Plan does not have to pre-approve Epogen for the enrollee.
You asked the Plan to pre-approve Epogen. You say that the enrollee needs this because of chemotherapy. The Plan denied your request. The Plan says that there was no evidence that enrollee has tried and failed Retacrit.
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 Epogen. Our reviewer says that Epogen is not medically reasonable and necessary for the enrollee in this case. The provided medical records do not indicate that the enrollee has tried and failed the required drug or that the Plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of Epogen. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Epogen have not been met. Therefore, we decided that the Plan does not have to pre-approve Epogen for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an electroencephalogram (95813) and monitoring for localization of cerebral seizures (95951) provided on March 26, 2019 through March 27, 2019.
You asked the Plan to pay for the electroencephalogram and monitoring. 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 include the actual date of service, therefore the service and modifier cannot be verified.
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 95813 and 95951 is not supported in the record. Specifically, there is insufficient documentation that these services were performed on the billed dates of service. Based on this information, we decided that Medicare rules for coverage of the electroencephalogram and monitoring have not been met. Therefore, we decided that the Plan does not have to pay for an electroencephalogram (95813) and monitoring for localization of cerebral seizures (95951) provided on March 26, 2019 through March 27, 2019.
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 August 8, 2019 through August 14, 2019.
You asked the Plan to waive the copayment for inpatient hospital care. You say that the stay was medically necessary. The Plan denied your request. The Plan says the stay is a readmission.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). 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 waive the copayment for inpatient hospital care. Our reviewer says that based on the provided medical records the readmission was not related to any condition that appears to have been present during the first admission. Therefore, the enrollee is asked to pay a $350 copayment per day, days 1-5 for inpatient hospital care. 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 August 8, 2019 through August 14, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on April 29, 2019.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their
denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent
nor urgent and prior authorization was not obtained to provide out-of-network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on April 29,
2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-rays provided on July 24, 2019.
You asked the Plan to pay for the diagnostic radiology procedures of the spine and pelvis (CPT 72100). You say that the x-rays showed a hip level difference and a shoe lift helped so that you no longer need visits. The Plan denied your request. The Plan says the x-rays are not covered by Medicare or the Plan.
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 service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the x-rays provided on July 24, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from July 31, 2019 to August 5, 2019.
You asked the Plan to waive the copayment for an inpatient hospital stay. 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $370 copayment per day for days 1-5 for inpatient hospital care. You had an inpatient hospital stay from July 31, 2019 to August 5, 2019. Therefore, you are responsible to pay a $370 copayment for days 1-5 (July 31, 2019 to August 4, 2019). $370 (copayment) x 5 (inpatient days) = $1,850.00. You have been asked to pay the total copayment amount of $1,850.00 for an inpatient hospital stay. An inpatient hospital 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 an inpatient hospital stay provided from July 31, 2019 to August 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a trigger point injection on August 29, 2019.
You asked the Plan to waive the copayment for a trigger point injection. You say that you were not informed that you would owe such a high copayment. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for surgery services provided in an outpatient hospital facility. You received a trigger point injection on August 29, 2019. A trigger point injection is an outpatient surgical procedure. Therefore, you are responsible to pay the $250 copayment. You have been asked to pay a $250 copayment for a trigger point injection. A trigger point 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 trigger point injection provided on August 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the leg splint application rendered to the enrollee on July 28, 2018.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 29515 is not supported.
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 29515 is application of short leg splint (calf to foot). We find that CPT code 29515 is not supported in the medical record. Specifically, there is no documentation that a short leg splint was applied. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the leg splint application rendered to the enrollee on July 28, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 27, 2019 by out of network provider, 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by a non-network provider without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The referring provider is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on August 27, 2019 by out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for limited oral evaluation - problem focused (D0140), intraoral - periapical first radiographic image (D0220), resin-based composite - one surface, posterior (D2391) and extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140) provided by an out-of-network provider on August 28, 2019.
You asked the Plan to pay for the dental services. You say that growing up you had a hard time going to the dentist and you finally found one dentist that you like. The Plan denied your request. The Plan says the services are not covered when received from an out-of-network provider.
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. Your EOC clearly states, exclusions and limitations: services performed by an out-of-network dentist if your plan does not have out-of-network coverage. Therefore, we decided that the Plan does not have to pay for limited oral evaluation - problem focused (D0140), intraoral - periapical first radiographic image (D0220), resin-based composite - one surface, posterior (D2391) and extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140) provided by an out-of-network provider on August 28, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services.You asked the Plan to pay forthe ambulance services. You say that on the date of service you had your granddaughter with you.You say that the ambulance was not able to transport you with your granddaughter, so you waited to instead ride with your daughter.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 does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on September 1, 2019. The ambulance benefit is a transportation benefit. When there is no transport,neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay forthe ambulance services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approveCoumadin.You asked the Plan to pre-approvethe Coumadin. You say that you have bleeding issues when you take Warfarin that you don't have when taking Coumadin. You say that your INR level is stable. You say that you benefit more from taking Coumadin than you do Warfarin.The Plan denied your request. The Plan says Drug coverage is limited to Part B covered drugs.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approveCoumadin.Benefits for the Coumadinmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the screening mammogram rendered to you on July 23, 2019.
You asked the Plan to pay for these services. You say that you were unaware of the time frame for the services.
The Plan denied your request. The Plan says the services exceed the benefit limit.
The Plan must follow Medicare rules. The rules say that a screening mammogram is covered once every 12
months for women age 40 and older.
The file shows that you received a screening mammogram on July 23, 2019. You previously received a
screening mammogram on September 20, 2018 for which the Plan approved and paid. The services on July 23,
2019 were performed less than 12 months from your previously covered screening mammogram. Therefore, we
decided that the Plan does not have to pay for the screening mammogram rendered to you on July 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the first 30 minutes of advance care planning (99497)
provided on April 15, 2019.
You asked the Plan to pay for advance care planning. You say that you would like reconsideration based on the
records submitted. The Plan denied your request. The Plan says the submitted medical records did not include
sufficient details to support that advance care planning including the explanation and discussion of advance
directives such as standard forms, by the physician or other qualified health care professional.
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 99497 is advance care planning including the explanation
and discussion of advance directives such as standard forms (with completion of such forms, when performed),
by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient,
family member(s), and/or surrogate.
We find that CPT code 99497 is not supported in the medical record. Specifically, the record does not detail
that advance care planning with an explanation of advance directives was rendered. Based on this information,
we decided that Medicare rules for coverage of advance care planning have not been met. Therefore, we
decided that the Plan does not have to pay for the first 30 minutes of advance care planning (99497) provided
on April 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99202) provided on August 22, 2019.
You asked the Plan to pay for these services. You say that you are requesting reconsideration of the Plan's denial. The Plan denied your request. The Plan says this service is not a covered benefit under your policy as the only covered chiropractic service is manual manipulation of the spine to correct subluxation.
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 service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the office visit (99202) provided on August 22, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the ambulance transport provided on February
14, 2019.
You asked the Plan to waive the copay for the ambulance transport. You say that you were told there would be
no cost for the ambulance transport. The Plan denied your request. The Plan says that the copay is your
financial responsibility.
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 $225
copay for per ambulance trip.
You have been asked to pay a $225 copay for the ambulance transport. The ambulance transport falls within
the ambulance trip 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 copay for the ambulance transport
provided on February 14, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for test strips, lancets, control solution, and batteries provided on August 3, 2019.
You asked the Plan to pay for test strips (A4253), lancets (A4259), control solution (A4256), and batteries
(A4235). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the Delivery
Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to
corroborate the Delivery Ticket.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a
physician order and proof of delivery.
The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the
items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in
this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have
a description of the items delivered. Therefore, we decided that the Plan does not have to pay for test strips,
lancets, control solution, and batteries provided on August 3, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on
June 4, 2019.
You asked the Plan to pay for drug tests. You say that these enrollee was referred by the treating physician and
the sample was collected at your laboratory. The Plan denied your request. The Plan says the denial of payment
for these services is correct, because the documentation submitted does not support the Place of Service (POS)
code billed on this claim and the does not include a valid physician order, lab requisition, or medical records
stating exactly which tests were to be performed.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific
lab services is required for covered lab services.
We looked at the file and Medicare rules. The documentation submitted does not include a physician order or
clear intent to order the specific lab tests billed on this claim. Based on this information, we decided that
Medicare rules for coverage of drug tests have not been met. Therefore, we decided that the Plan does not have
to pay for drug testing provided on June 4, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp for the enrollee.
You asked the Plan to pre-approve Aranesp. You say that the enrollee needs this for chronic kidney disease.
The Plan denied your request. The Plan says that they did not receive documentation or medical records
supporting the medical necessity for a step therapy exception.
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 Aranesp. Our reviewer says that
Aranesp is not medically reasonable and necessary for the enrollee in this case. The provided medical records
do not indicate that the patient has tried and failed the required drug or that the Plan's required drug would
likely be less effective and/or likely have adverse effects for the enrollee. Our physician reviewer found that the
enrollee's condition does not meet criteria for coverage of Aranesp.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have
to pre-approve Aranesp for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 CFR 422.101.
The rules say that providers must report services correctly. Procedures should be reported with the CPT code that describes the services performed. You can find this rule in the Medicare National Correct Coding Initiative Manual, Chapter I(A).
If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.