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

We decided that the Plan does not have to pay for laboratory services provided on July 16, 2019.You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says that the enrollee must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan. 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 servicesat issue. We found no exception that would require thePlan to pay for these services. Therefore, we decided that the Plan does not have to pay for laboratory services provided on July 16, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe emergency room visit provided from September 12, 2019 to September 13, 2019.You asked the Plan to waive the copayment forthe emergency room visit. You say that you were moved to a hospital bed on one of the hospital floors and your wife asked if you were being admitted. You say you should not be responsible for the copayment. 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, accurateterms 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 Medicare-covered emergency room visit. You have been asked to pay a $100 copaymentfor the emergency room visit. The emergency room visit falls within the "Outpatient hospital services" benefit category. The medical record shows you were admitted into observation.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 forthe emergency room visit provided from September 12, 2019 to September 13, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe emergency room visit provided on September 11, 2019.You asked the Plan to waive the copayment forthe emergency room visit. You say that you dispute the $90 charge and you should not have to pay. 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 $90 copayment for each emergency room visit. You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls within the "Emergency 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 forthe emergency room visit provided on September 11, 2019.
Appeal type: Imaging
Decision: Unfavorable

Wedecided that the Plan does not have to waive the copayment forthe shoulder x-ray provided on September 20, 2019.You asked the Plan to waive the copayment forthe shoulder x-ray. You say that you never saw the provider. You say that you did not require a shoulder x-ray.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 $15 copayment for x-rays. You have been asked to pay a $15 copayment for the shoulder x-ray. The shoulder x-ray falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The records show that a shoulder x-ray was performed. 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 forthe shoulder x-ray provided on September 20, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ambulance ride provided on October 21, 2019.You asked the Plan to waive the copayment forthe ambulance ride. You say that this was an emergency and there was no chance for a referral.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 $265 copayment per date of services regardless of the number of trips for emergent and non-emergent ground ambulance. You have been asked to pay a $265 copayment for the ambulance ride. The ambulance ride falls within the "Ambulance services" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment forthe ambulance ride provided on October 21, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approveSelective Internal Radiation Therapy(SIRT) using Yttrium-90 microspheres for the enrollee. You asked the Plan to pre-approvethe requested services. You say that this treatment is the enrollee's best option to control and downsize the hepatic metastases.The Plan denied your request. The Plan says the requested treatment is only covered for bowel associated cancers.The Plan follows Medicare rules. Medicare rules say that Treatment with Yttrium-90 Microspheresis only covered under certain medical 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 the requested services. Our physician reviewer found that the request is for Y90 TheraSpheres embedded with glass beads. There are slight technical differences between SIR-spheres and Therespehres. While SIR spheres are FDA-approved for colorectal cancer liver metastases and TheraSpheres are approved for hepatocellular carcinoma, the principlesof using a radioactive embolizing agent is the same for both, and thus the concept of radioembolization applies to both. The use of SIR-Spheres (Sirtex) vs. TheraSpheres tends to be institution-dependent, and there are studies of the use of either TheraSpheres or SIR-Spheres (Sirtex) for hepatocellular carcinoma. The most recent NCCN guidelines v4.2019 do not differentiate between glass and resin "yttrium-90 microspheres" and explicitly state that treatment is "accomplished through catheter-based administration of microspheres (glass or resin) embedded with yttrium-90." The Medical records show no change in the enrollee' medical status, or the need for the requested treatment at this time.  Therefore based on the LCD criteria, Medicare coverage criteria arenot met.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-approveSelective Internal Radiation Therapy (SIRT) using Yttrium-90 microspheres for the enrollee.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approveEuflexxa for the enrollee .You asked the Plan to pre-approveEuflexxa. You say that the enrollee only has lasting relief with Euflexxa.ThePlan denied your request. The Plan says the enrollee has not had previous treatment, contraindication, or intolerance to Orthovisc and Monovisc.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 Euflexxa. Our physician reviewer found that the enrollee has bilateral primary osteoarthritis of the knees. The Plan requires a trial of drug Orthovisc and Monovisc before they will approve the requested drug. The documentation does not show that the enrollee has tried and failed the required drugs. The documentation does not support that Orthovisc and Monovisc would likely be less effective, 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approveEuflexxa for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe inpatient stay provided from November 1, 2019 through November 4, 2019.You asked the Plan to waive the copayment forthe inpatient stay. You say that you could have been discharged earlier.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 $400 per day, days 1-4 for each inpatient stay.You have beenasked to pay $1,200 for the inpatient stay. ($400/day x 3 days = $1,200). 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 forthe inpatient stay provided from November 1, 2019 through November 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the coinsurance forthe medical eye exam provided on October 8, 2019.You asked the Plan to reduce the coinsurance forthe medical eye exam. You say that you thought the provider was in-network. You say you are on a limited income would like help. 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 45% coinsurance for out-of-network Medicare-covered eye exam. You have been asked to pay $31.94 which is 45% of the allowed amount for the medical eye exam. The allowed amount is $70.97. ($70.97 x 45% = $31.94). The medical eye exam falls within the "Vision care" benefit category. The record shows the provider is out-of-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 reduce the coinsurance forthe medical eye exam provided on October 8, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on August 13, 2019, August 27, 2019, September 19, 2019 and October 3, 2019.You asked the Plan to pay for the psychotherapy services. You say that no one at the provider's office told you that this doctor was out-of-network with your insurance plan. ThePlan 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 servicesat 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 psychotherapy services provided on August 13, 2019, August 27, 2019, September 19, 2019 and October 3, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe BLS non-emergency ambulance transportation provided November 8, 2019.You asked the Plan to pay forthe ambulance transport. You say that the records should support the necessity of the service in dispute.The Plan denied your request. The Plan says the information provided does not support medical necessity for ambulance transport.Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 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 ambulance transport. Our reviewer says that based on the provided documentation, the ambulance transportation was not medically necessary. Our physician reviewer found the the documentation does not support that a stretcher van, wheelchair van, taxi, private care, or other vehicle were contraindicated. The enrollee was able to ambulate and was not in any distress. The documentation does not support that the enrollee required the expertise, services, and lifesaving equipment while transporting to the other facility.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 ambulance transport have not been met.Therefore, we decided that the Plan does not have to pay forthe BLS non-emergency ambulance transportation provided November 8, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran X-ray provided on November 11, 2019.You asked the Plan to waive the copayment foran X-ray. You say that you disagree with the $15 charge.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 $15 copayment for an X-ray. You have been asked to pay a $15 copayment for an X-ray. An X-ray falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment foran X-ray provided on November 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Freestyle Libre 14 day sensors.You asked the Plan to pre-approvethe sensors. You say that  The Plan denied your request. The Plan says that you do not make criteria for coverage.The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs and supplies are covered when the above criteria have been met.We looked at the file and Medicare rules. The file indicates you are not treated by insulin injections three or more times a day. Based on this information, we decided that Medicare rules for coverage of the sensors have not been met.Therefore, we decided that the Plan does not have to pre-approveFreestyle Libre 14 day sensors.
Appeal type: Drugs
Decision: Unfavorable

You asked the Planto pre-approvethe drug. You say that this is medically necessary.The Plandenied your request. The Plansaysthe requested drug is subject to step therapy.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 the drug. Our reviewer says that the requested drug does not meet the step therapy guidelines. Our physician reviewer found there is no indication of a trial and failure of the requiredstep therapy drugs. The provided medical records do not indicate that the plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee.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 drug have not been met.Therefore, we decided that the Plandoes not haveto pre-approveOrencia (J0129) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for neurology services (CPT 95937 and CPT 95940) provided to the enrollee on August 29, 2019.You asked the Plan to pay for the services. You say that this should be paid for.The Plan denied your request. The Plan says the denied codes remain 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 the denied codes is:CPT 95940:Continuous intraoperative neurophysiology monitoring in the operating room, one on one monitoring requiring personal attendance, each 15 minutes (List separately in addition to code for primary procedure)CPT 95937:Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method 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 services. Our reviewer says that the services at issue in this case were not coded correctly. Our physician reviewer found the physician conducting the intraoperative monitoring was not located inside the OR. Therefore, the billing of CPT 95940 is not supported. There is no evidence that diagnostic neuromuscular junction testing was performed. Therefore, the billing of CPT 95937 is not supported.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 pay for neurology services (CPT 95937 and CPT 95940) provided to the enrollee on August 29, 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 September 4, 2019 to September 13, 2019.You asked the Plan to waive the copayment for an inpatient hospital stay. You say that 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 $300 copayment per day for days 1-5 for inpatient hospital care. You had an inpatient hospital stay from September 4, 2019 to September 13, 2019. Therefore, you are responsible to pay a $300 copayment for days 1-5 (September 4, 2019 to September 8, 2019). $300 (copayment) x 5 (inpatient days) = $1,500.You have been asked to pay the total copayment amount of $1,500 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 from September 4, 2019 to September 13, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe CPAP device provided on July 4, 2019.You asked the Plan to waive the coinsurance forthe CPAP device. You say that the following months had a cheaper cost. You say that the copayments should be equal.The Plan denied your request. The Plan says the coinsurance 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% for Medicare-covered equipment and supplies from an in-network provider. You have been asked to pay $10.65, which is 20% of the allowed amount for the CPAP device. The allowed amount is $53.26 (20% x $53.26 = $10.65). The CPAP device falls within the "Durable medical equipment (DME) and related 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 coinsurance forthe CPAP device provided on July 4, 2019.