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

We decided that the Plan does not have to waive the copayment for the joint fusion procedure provided on January 7, 2020.
You asked the Plan to waive the copayment for the joint fusion procedure. You say that the surgery was performed at an outpatient surgery center. You say that the charge should be $255. 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 $345 copayment for surgery services at an in-network outpatient hospital.
You have been asked to pay a $345 copayment for the joint fusion procedure. The joint fusion procedure falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show that the procedure was billed by the hospital. 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 joint fusion procedure provided on January 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical supplies provided on November 26, 2019 by an
out of network provider.
You asked the Plan to pay for the medical supplies. You say that you were not aware a pre-authorization was
needed. The Plan denied your request. The Plan says you did not have authorization for the supplies from an
out-of-network supplier.
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 at issue in this appeal. The Plan did not pre-approve the items at issue. We
found no exception that would require the Plan to pay for these items. Therefore, we decided that the Plan does
not have to pay for the medical supplies provided on November 26, 2019 by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit to be provided by an out of network
(OON) provider.
You asked the Plan to pre-approve an OON office visit. You say that there are not contracted neurosurgeons
who can perform an endoscopic thoracic discetomy. The Plan denied your request. The Plan says the requested
services are available in-network.
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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
The provider at issue in this case is not a network provider with the Plan. 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 an OON office visit. Our reviewer says that the criteria for out-of-network
care has not been met. Our physician reviewer found it is not medically necessary for you to see an OON
thoracic surgeon. Current literature still shows endoscopic thoracic surgery to be experimental. You can be
treated safely by in-network providers.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of an OON office visit have not been met.
The Plan has network providers available who can provide the items/services at issue in this appeal. We found
no exception that would require the Plan to pre-approve an OON office visit. Therefore, we decided that the
Plan does not have to pre-approve an office visit to be provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the elbow surgery provided on February 7,
2020.
You asked the Plan to waive the copayment for the elbow surgery. You say that your surgery was rescheduled
from the morning to the late afternoon. You say you should not be charged for a full day at the hospital. 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 $325
copayment for each Medicare-covered outpatient hospital facility visit.
You have been asked to pay a $325 copayment for the elbow surgery. The elbow surgery falls within the
"Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical
centers" benefit category. The record shows the surgery was completed later in the afternoon.
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 elbow surgery provided on February 7, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Talimogene laherparepvec (J9325).
You asked the Plan to pre-approve Talimogene laherparepvec. You say that this is the only treatment option. The Plan denied your request. The Plan says this use is not supported.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 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 Talimogene laherparepvec. Our reviewer says that the use of Talimogene laherparepvec is not supported in this case. Our physician reviewer found Talimogene laherparepvec is not FDA approved for the requested indication, the treatment of recurrent squamous cell skin cancer. None of the CMS approved compendia support the requested use. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Talimogene laherparepvec have not been met. Therefore, we decided that the Plan does not have to pre-approve Talimogene laherparepvec (J9325).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the ranibizumab injections provided from September 13, 2019 to November 15, 2019. You asked the Plan to waive the coinsurance for the injections. You say that you have never paid for these services before. The Plan denied your request. The Plan says that the cost share was 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% coinsurance for each Medicare-covered Part B drug. You have been asked to pay a 20% coinsurance for the injections. The injections fall within the Medicare-covered Part B drug benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the ranibizumab injections provided from September 13, 2019 to November 15, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee is in need of the requested rehab following his second stroke. You say that the enrollee's providers have advised that if he does not get the rehab he won't have a full recovery. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a SNF level of care. Ongoing pain medication and other medication management, skin/wound care, and daily therapy can be provided at a skilled nursing facility (SNF). The enrollee is mostly maximum assist for functional transfers and activities of daily living. A less intensive, longer duration of therapy may be more appropriate. It is not clear the enrollee would be able to fully benefit from and/or participate in an IRF level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee required moderate assistance for bed mobility and stand up and sit down. The enrollee required minimal assistance to walk 10 feet. The documentation does not support that the enrollee requires the intensive of services provided at an IRF. The enrollee is not shown to require fifteen hours per week of rehabilitative services with regular physician evaluation. The enrollee's care needs can be met at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health certification (G0180) provided on April 26, 2019 by an out of network (OON) provider.
You asked the Plan to pay for an OON home health certification. You say that you were not aware the enrollee was no longer on Original Medicare. The Plan denied your request. The Plan says this service was not authorized.
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 home health certification (G0180) provided on April 26, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

e decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested admission is not medicallynecessary.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee was medically stable. The documentation does not support evidence of the need for supervision by physical medicine and rehabilitation Physician or needs acute rehab nursing care. The enrollee required maximum assistance for almost all activities of daily living and mobility. The documentation supports that the enrollee may benefit from further physical therapy and occupational therapy but does not require an intensive therapy program. The enrollee's care needs can be met at a lower level of care.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), first intraoral periapical x-ray (D0220), 2D oral/facial photographic image (D0350), and occlusal adjustment (D9951) provided on January 8, 2020.You asked the Plan to pay for the problem focused limited oral evaluation, first intraoral periapical x-ray, 2D oral/facial photographic image, and occlusal adjustment. You say that these services should be covered because they were for a basic toothache.The Plan denied your request. The Plan says these services are not covered benefits under your dental plan.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), first intraoral periapical x-ray (D0220), 2D oral/facial photographic image (D0350), and occlusal adjustment (D9951) provided on January 8, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for hydration infusion (96360 and 96361)
provided on November 19, 2019.
You asked the Plan to waive the copayment for the hydration infusion. You say that you would like
reconsideration because you were not told the copayment would be this much. The Plan denied your request.
The Plan says the copayment for this service was 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 $275
copayment for outpatient surgery.
You have been asked to pay a $213.69 copayment for the hydration infusion. You have been asked to pay the
allowed amounts of $177.72 and $35.97 for these services. This is less than your contracted copayment for
outpatient surgery.
The hydration infusion falls within the outpatient surgery benefit category. This means that you have been
asked to pay less than 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 hydration infusion (96360 and 96361) provided on November 19,
2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on March 11, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-network provider on March 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the intravitreal injections provided on January 14, 2020 and January 20, 2020.
You asked the Plan to waive the copayments for the intravitreal injections. You say that you have never been charged a copayment for the injections for the last six years. You say you do not think a copayment should apply. 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 $30 copayment for each specialist visit for Medicare-covered benefits. You have been asked to pay a $30 copayment for each of the intravitreal injections. The intravitreal injections fall within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show the intravitreal injections are considered a surgical procedure which were received in a specialist office.
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 intravitreal injections provided on January 14, 2020 and January 20, 2020.
Our decision is only about the 2020 services. If you have any questions about prior years billing, please contact the plan directly.
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 transfer to an LTACH is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. The Plan states the treating physician does not support the transfer to an LTACH.
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. The Medical records provided do not support the transfer to an LTACH. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital discharge day management (99239) provided January 4, 2019.
You asked the Plan to pay for the hospital discharge day management. You say that the services were medically necessary and correctly billed. The Plan denied your request. The Plan says the records do not support the code 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 99239 is hospital discharge day management of more than 30 minutes. We find that CPT code 99239 is not supported in the medical record. Specifically, the record does not show that more than 30 minutes were spent on this service. Based on this information, we decided that Medicare rules for coverage of the hospital discharge day management have not been met. Therefore, we decided that the Plan does not have to pay for hospital discharge day management (99239) provided January 4, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided from
December 31, 2019.
You asked the Plan to waive the copayment for the emergency room visit. You say that you are not willing to
pay this bill because you went to the doctor and you did not know what they were going to do. 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 for the
emergency room visit provided from December 31, 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 by an out-of-network provider on December 18, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are available in-network.
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 services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-network provider on December 18, 2019.