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

We decided that the Plan does not have to waive the copayments for extracapsular cataract removals provided on July 15, 2019 and August 5, 2019.
You asked the Plan to waive the copayments for extracapsular cataract removals. You say that you have never been charged in the past and 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 $75 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You received extracapsular cataract removals on July 15, 2019 and August 5, 2019. Therefore, you are responsible to pay a $75 copayment per each surgery. The total amount you owe is: $150.00. You have been asked to pay the total copayment amount of $150.00 for extracapsular cataract removals. Extracapsular cataract removals fall 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 copayments for extracapsular cataract removals provided on July 15, 2019 and August 5, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for an emergency department visit (99284) provided on July 29,
2019.
You asked the Plan to pay for the emergency department visit. You say that 99284 is the appropriate code for
the services rendered. The Plan denied your request. The Plan says the level of service for this Evaluation and
Management code was reduced based on the diagnostic information on your claim.
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 99284 is emergency department visit for the evaluation
and management of a patient, which requires these 3 key components: A detailed history; A detailed
examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care
with other physicians, other qualified health care professionals, or agencies are provided consistent with the
nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high
severity, and require urgent evaluation by the physician, or other qualified health care professionals but do not
pose an immediate significant threat to life or physiologic function.
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 emergency department visit. Our
reviewer says that the blood work was not unreasonable, but as it was non-actionable, additional testing was
not indicated in the ED. Our physician reviewer found the nature of the complaint was not of high severity and
does not warrant the level of services provided/billed.
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 emergency department visit. have not been met. Therefore, we decided that
the Plan does not have to pay for an emergency department visit (99284) provided on July 29, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xtandi for the enrollee.
You asked the Plan to pre-approve Xtandi. The Plan denied your request. The Plan says Xtandi to be administered at home is not covered under the Part B benefit. The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Xtandi for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Cimzia prefilled syringe kit.
You asked the Plan to pre-approve self-administered drugs. You say that the enrollee has failed prior medications but has had excellent sustained response to this drug. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits. The Plan says that the enrollee's Medicare Part D prescription drug benefits may be administered.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Cimzia prefilled syringe kit.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Praluent injection 150mg/ml for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says this medication does not fall under Part D coverage.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Praluent injection 150mg/ml for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda
You asked the Plan to pre-approve Keytruda. You say that Keytruda demonstrated anti-tumor activity, and was well tolerated in advanced adrenocortical carcinoma. The Plan denied your request. The Plan says the drug is labeled experimental for the enrollee's tumor.
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 Keytruda. Our physician reviewer found that Keytruda is not FDA approved for use in adrenocortical carcinoma, unless the tumor is microsatellite instability high/mismatch repair deficient, the patient has progressed on prior therapy, and have no satisfactory alternative treatments. The documentation does not indicate that those conditions pertain to the enrollee in this case. The CMS-approved compendia do not support the requested use. This reviewer found no citations to support the request in a PubMed search. The abstract submitted by the prescriber has not been published in a peer reviewed journal as of the date of this review. The requested use is not listed as not indicated, not supported or not recommended in any of the compendia. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xiidra eye drops for the enrollee.
You asked the Plan to pre-approve Xiidra. 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-approve Xiidra eye drops for the enrollee.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ED visit provided on August 21, 2019.
You asked the Plan to waive the copayment for the ED visit. You say that you were transferred based on an incorrect diagnosis. You say that there would have been no transfer if you weren't misdiagnosed. 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 $85 for each visit to an emergency room. You have been asked to pay an $85 copayment for the ED visit. The ED 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 ED visit provided on August 21, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the glucose monitor, test strips, lancets, control solution, and lancet device provided from August 8, 2019 to October 27, 2019.
You asked the Plan to pay for the glucose monitor (E0607), test strips (A4253), lancets (A4259), control solution (A4256), and lancet device (A4258). 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 the glucose monitor, test strips, lancets, control solution, and lancet device provided from August 8, 2019 to October 27, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the services required by the enrollee
exceeds the clinical capabilities of lower levels of care. The Plan denied your request. The Plan says the
enrollee does not have clinical conditions that cannot be appropriately treated in the current hospital.
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 physician
reviewer found that the enrollee is currently undergoing treatment at an acute care hospital (ACH) having been
admitted with respiratory failure requiring intubation/ventilation. The enrollee was subsequently treated for
pneumonia and his baseline end-stage renal disease. He suffered a cardiac arrest during a hemodialysis session
and eventually received a tracheotomy. Recently, the enrollee has been showing signs of tolerating ventilator
weaning and is participating in rehabilitative services. As LTACHs and ACHs are licensed to provide the same
level of care, there is no advantage in transferring the enrollee to the LTACH.
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-approve long term acute care hospital (LTACH) services.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Prolia (denosumab).
You asked the Plan to pre-approve Prolia. You say that the enrollee has severe osteoporosis and oral bisphosphonates are contraindicated for the enrollee. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because the Plan requires a trial of Zoledronic Acid before it will approve use of Prolia.
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 Prolia. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested Prolia. Our physician reviewer found the enrollee has not tried and failed the Plan's preferred drug of Zoledronic Acid. The documentation does not support that Zoledronic Acid would likely be less effective and/or would 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 Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Prolia (denosumab).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on July 12, 2019.
You asked the Plan to pay for the pump assembly and operation. You say that the specialist is independent of the surgeon and hospital. The Plan denied your request. The Plan says payment for this service is included in the DRG payment to the facility.
The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the pump assembly and operation have not been met. Specifically, payment for this service is included in the DRG payment to the facility. Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on July 12, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for echocardiography (an echogram) (93325, 93320, 93351)
provided on July 11, 2019 by an out of network provider.
You asked the Plan to pay for an echogram. You say that the claim for this date of service was denied for lack
of authorization. You are requesting a review of the documents for medical necessity. You were unaware the
rendered service required authorization at the time that the service was rendered. The Plan denied your request.
The Plan says services rendered out of service area are not emergent and not covered.
According to the medical records, the member moved out of the service area prior to the date of service and
may be eligible for Medicare. As per the member's handbook, if they move outside of the service area, they
cannot stay in this 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 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 echocardiography (an echogram) (93325, 93320,
93351) provided on July 11, 2019 the by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the tetanus vaccine you received on October 4, 2019.
You asked the Plan to pay for the tetanus vaccine. You say that you were not aware this was not covered. The Plan denied your request. The Plan says this is not a covered benefit.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the tetanus vaccine. The Plan follows the same rules. The records do not show that you have been injured or directly exposed to any illness related to the tetanus vaccine. Therefore, we decided that the Plan does not have to pay for the tetanus vaccine you received on October 4, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a laboratory test provided on July 30, 2019.
You asked the Plan to pay for the test. The Plan denied your request. The Plan says you 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 service 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 a laboratory test provided on July 30, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 2 extractions and 2 endosteal implants provided on February 13, 2019.
You asked the Plan to pay for the extractions and endosteal implants. You say that these extractions were done due to an abscess. The Plan denied your request. The Plan says your coverage required an authorization for these services. The Plan also says that there is no record of an authorization for these services on file.
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 2 extractions and 2 endosteal implants provided on February 13, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the biopsy services coded 38525 provided on August 19, 2019.
You asked the Plan to pay for the biopsy services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.
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 38525 is Biopsy or excision of lymph node(s); open, deep axillary node(s). We find that CPT code 38525 is not supported in the medical record. Specifically, this code was not the most appropriate service performed for the place of service 11 (office location). The Medicare rule for payment of code 38525 has not been met. Based on this information, we decided that Medicare rules for coverage of the biopsy services have not been met. Therefore, we decided that the Plan does not have to pay for the biopsy services coded 38525 provided on August 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee on August 16, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed with the incorrect POS code.
The Plan must follow Medicare rules. Medicare rules say that although follow-up inpatient telehealth consultations are specific to telehealth, these services must be billed with POS 02 to identify the telehealth technology used to provide the service. We looked at the file and Medicare rules. The services in question were follow-up inpatient telehealth consultations. The services were billed with incorrect POS code 31. Per Medicare rules, these services must be billed with POS code 02. 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 the services provided to the enrollee on August 16, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the reconstruction of an eyelid provided on September 13, 2019.
You asked the Plan to waive the copayment for the reconstruction of an eyelid. You say that the claims were processed correctly and you are being charged the correct amount. 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 $400 copayment for outpatient hospital surgery services. You received the reconstruction of an eyelid on September 13, 2019. Therefore, you are responsible to pay the $400 copayment. You have been asked to pay a $400 copayment for the reconstruction of an eyelid. The reconstruction of an eyelid 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 the reconstruction of an eyelid provided on September 13, 2019.