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

We decided that the Plan does not have to waive the copayment fora CT scan provided on June 24, 2019.You asked the Plan to waive the copayment fora CT scan. You say that you disagree with the high charges and feel that you should have went to the emergency room instead.The Plan denied your request. The Plan says the claims were processed correctly,and you are being charged the correct amount.The rulessay 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 $225 copayment for diagnostic radiology. You have been asked to pay a $225 copayment for a CT scan. A CT scan 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 fora CT scan provided on June 24, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an upper endoscopy with Botox for enrollee.You asked the Plan to pre-approve these services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that Botox is covered for specific indications only. 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has diabetic gastroparesis with abdominal pain and fullness while eating. A gastric scan showed significant delayed gastric emptying. The Medicare rules state that Botox is not covered for any spastic condition of smooth muscle. Furthermore, there is not enough evidence that this treatment of gastroparesis is superior to other established treatments. Studies do not support the novel treatment of intrapyloric injection of botulinum toxin for the treatment of gastroparesis. The use of Botox is therefore not reasonable or medically necessary 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approvean upper endoscopy with Botox for enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing rendered to the enrollee on April 19, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 forthe drug testing rendered to the enrollee on April 19, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for SNF care provided from May24, 2019 through June 15, 2019.You asked the Plan to waive the copayment forSNF care. You say that you should not have to pay the bill because it should be covered under your "returning home plan".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 SNF care provided from May 24, 2019 through June 15, 2019. You are asked to pay a $50 copayment per day for days 21-100. 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 SNF care provided from May 24, 2019 through June 15, 2019
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe Revlimid 5mg capsule medication.You asked the Plan to pre-approvethis medication. You say that you are requesting a reconsideration of the Plan's denialas the patient needsongoing treatment for her condition.The Plan denied your request. The Plan says this medication is not a covered benefit under the member's contractual policy.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which arecovered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approvethe Revlimid 5mg capsule medication.Benefits for this medicationmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered to enrollee on July 5, 2019.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 codes 15734-AS and 15734-AS-59 are 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 15734 is muscle, myocutaneous, or fasciocutaneous flap; trunk.We find that CPT code 15734 is not supported in the medical record. Specifically, the operative report does not include documentation of a muscle, myocutaneous, or fasciocutaneous flap from the trunk. 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 services rendered to enrollee on July 5, 2019.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Actemra.You asked the Plan to pre-approve Actemra. You say that the enrollee needs a different class of medication.The Plan denied your request. The Plan says that the enrollee must try and fail Enbrel before Actemra can be covered.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. The Plan contract states that step therapy rules do not apply to Part B drugs. 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 Actemra. Our reviewer says that Actemra is medically necessary for the enrollee in this case. Our physician reviewer found the enrollee has rheumatoid arthritis. Treatment with methotrexate, Humira, and Xeljanz has failed to produce sustained improvement. The documentation supports that the Actemra is safe, effective, and medically necessary for the patient.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Actemra have been met.Therefore, we decided that the Plan has to pre-approve Actemra.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an initial new patient preventive medicine evaluation (99387) provided on July 12, 2019 by an out of network (OON) provider.
You asked the Plan to pay for an initial new patient preventive medicine evaluation. You say that you sent medical records and are seeking a review. You are enrolled in all 7 Medicare complete plans and request payment along with interest. The Plan denied your request. The Plan says the physician is a non-network provider who does not work with the member's health plan, and the member self-directed for care. The member's primary care provider did not refer for services. The health plan requires utilization of network providers when possible and available and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for an initial new patient preventive medicine evaluation (99387) provided on July 12, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Cyclobenzaprine for the enrollee.
You asked the Plan to pre-approve this drug. The Plan denied your request. The Plan says that this 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 drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Cyclobenzaprine for the enrollee.
Benefits for this drug 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: Practitioner Services
Decision: Favorable

We decided that the Planhasto pre-approvea cervical/thoracic epidural injection.You asked the Planto pre-approvethe injection. You say that this is medically necessary, as you are in pain all the time, and are living on a heating pad.The Plandenied your request. The Plansaysthatfor a patient with low back pain only, a simple disc bulge, or annular tear/fissure is insufficient to justify the performance of an epidural.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the injection. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the health plan incorrectly refers to low back pain, over-utilization, and a lack of imaging. This is a request for a cervical transforminal epidural steroid injection. TheCT myelogram showed narrowing at C4-C5.  This procedure 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 the injection have been met.Therefore, we decided that the Planhas to pre-approvea cervical/thoracic epidural injection.If the Plandoes not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information toreview. The Plan has to show us the mistake and/orsend us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a left L1-2 far lateral microdiscectomy.
You asked the Plan to pre-approve the back surgery. You say that you are in excessive pain and surgery has been recommended. The Plan denied your request. The Plan says that the documentation indicates that your conservative therapy has focused on your hip and the proposed surgery is to address your lower back pain.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the back surgery. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found functional limitations are noted in activities of daily living and mobility. Clinical exam findings have documented a focal motor deficit consistent with imaging evidence of a left far lateral foraminal L1/2 disc herniation with left L1 nerve root compromise, and possible disc extrusion. You have failed to improve despite recent reasonable conservative treatment, including activity modification, multiple medications, home exercise, and swimming. You are status post left total hip replacement and revision surgery with no evidence of post-operative complications. You underwent a left hip trochanteric bursa injection without improvement. Current evidence based medical literature would support the recommended surgical intervention as safe and effective including in the absence of smoking cessation 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 back surgery have been met. Therefore, we decided that the Plan has to pre-approve a left L1-2 far lateral microdiscectomy.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy provided on September 9,
2019, September 17, 2019 and September 19, 2019.
You asked the Plan to waive the copayment for physical therapy. You say that your last appointment was not
necessary. You say that the services charged were not provided. The Plan denied your request. The Plan says
the copayments applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30
copayment for each Medicare-covered physical, occupational, or speech language therapy visit.
You have been asked to pay a $30 copayment for each physical therapy visit. The total amount you owe is $90
($30/visit x 3 visits = $90). Physical therapy falls within the "Outpatient rehabilitation services" benefit
category. The records show that you received physical therapy on each date of service. 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 physical therapy provided on September 9, 2019, September 17,
2019 and September 19, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. The Plan denied your request. The Plan says LTACH admission is not medically necessary.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that recent plans for discharge in the near future are reasonable, however, ongoing pulmonary issues requiring closer monitoring, traumatic brain injury assessment, and nursing care as well as continued antibiotics, should be supervised in an acute care setting for some time longer. Based on the provided recent records, this additional supervision and care shouldn't last more than 25 days. The services available and covered at the current facility are sufficient, and there are no additional services needed that only the LTACH would offer. Therefore, this request for LTACH services will be considered not medically necessary at this time.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for home ventilator, any type, used with non-invasive interface, (e.g., mask, chest shell) (CPT Code E0466) provided from April 24, 2019 through September 24, 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 because you are on a fixed income.The Plan denied your request. The Plan says the claims were 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 a home ventilator, any type, used with non-invasive interface, (e.g., mask, chest shell) (CPT Code E0466) provided from April 24, 2019 through September 24, 2019. You are asked to pay 20% coinsurance 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 forhome ventilator, any type, used with non-invasive interface, (e.g., mask, chest shell) (CPT Code E0466) provided from April 24, 2019 through September 24, 2019
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the debridement service provided on August 30, 2019.You asked the Plan to waive the copayment for the debridement service. You say that the wound care you received is not a surgery. 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 $295 copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $295 copayment for the debridement service.You have been asked to pay a $199 copayment for the debridement service. The debridement service falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. The record shows that debridement is considered a surgical procedure. 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 debridement service provided on August 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the walker provided on August 19, 2019.You asked the Plan to waive the coinsurance for the DME. You say that you were told this was part of the treatment and you would not be responsible for the cost.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 the walker provided on August 19, 2019. You are asked to pay 10% coinsurance 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 the walker provided on August 19, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that thePlan does not have to pay for drug testing services provided to the enrollee on July 22, 2019.You asked the Plan to pay forthe services. You say that this should be paid for.The Plan denied your request. The Plan says the documentation submitted did not include a physician order/lab requisition or medical records stating exactly tests were to be performed.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The documentation submitted did not include a physician order/lab requisition or medical records stating exactly tests were to be performed. 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 fordrug testing services provided to the enrollee on July 22, 2019
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for infusion supplies for external drug infusion pump per cassette or bag provided on April 10, 2019 and April 24, 2019.You asked the Plan to pay for the infusion supplies for external drug infusion pump per cassette or bag. The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for infusion supplies for external drug infusion pump per cassette or bag provided on April 10, 2019 and April 24, 2019.