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

We decided that the Plan does not have to waive the coinsurance for infusion services (96375, 96367, 96415, 96413 and J9312) provided on August 13, 2019.
You asked the Plan to waive the coinsurance for the infusion services. You say that the coinsurance applied to this claim is very much out of line with your previous treatment. The Plan denied your request. The Plan says this claim processed correctly per the 2019 EOC.
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% coinsurance for Medicare Part B Prescription Drugs.
You have been asked to pay $11.34 for IV infusion (96367). The allowed amount for this service is $56.68 20% of $56.68 is $11.34.
You have been asked to pay $7.19 for a therapeutic injection (96375). The allowed amount for this service is $35.94. 20% of $35.94 is $7.19.
You have been asked to pay $54.72 for chemo administration (96413). The allowed amount for this service is $273.59. 20% of 273.59 is $54.72.
You have been asked to pay $11.34 for chemo infusion (96415). The allowed amount for this service is $56.68. 20% of $56.68 is $11.34.
You have been asked to pay $705.49 for rituximab (J9312). The allowed amount for this service is $3,527.45. 20% of $3,527.45 is $705.49.
You have been asked to pay a total of $790.08 for the infusion services. The correct 20% coinsurance has been applied to this claim. The infusion services fall within the Medicare Part B Prescription Drugs 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 infusion services (96375, 96367, 96415, 96413 and J9312) provided on August 13, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve removal of benign odontogenic cyst or tumor (D7451).
You asked the Plan to pre-approve removal of benign odontogenic cyst or tumor (D7451). You say that you
would like the plan to reconsider their denial. The Plan denied your request. The Plan says removal of benign
odontogenic cyst or tumor described by code D7451 is not a covered benefit under Medicare or the Plan's
dental supplemental benefit.
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 removal of benign
odontogenic cyst or tumor (D7451) is not among those covered under this benefit. Therefore, we decided that
the Plan does not have to pre-approve removal of benign odontogenic cyst or tumor (D7451).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forbilateral ankle foot orthoses (CPT Code L1971) provided to the enrollee on March 12, 2019.You asked the Plan to pay forthe orthoses. You say that the claim should be paid. The Plan denied your request. The Plansays the Medicare rules have not been met.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay forbilateral ankle foot orthoses (CPT Code L1971) provided to the enrollee on March 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Urolift system.
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your request. The Plan says there was no documentation of ultrasound testing or that urine peak flow rate was performed.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 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 system. Our reviewer says that the requested system is not considered medically reasonable and necessary in this case. Our physician reviewer found there is insufficient information in the medical records provided in this case to determine whether the Urolift 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 system have not been met. Therefore, we decided that the Plan does not have to pre-approve the Urolift system.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay fora home visit (99342), and vaccines (90471, 90688) provided on October 4, 2018 by out of network provider.You asked the Plan to pay fora home visit and vaccines. You say that you are disputing the denied claim for medical services.The service rendered was medically necessary due to the nature of the patient's condition.The Plan denied your request. The Plan says no prior authorization was obtained for the non-participating provider. The services provided by the non-participatingprovider were denied coverage since the services can be provided by participating providers.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 fora home visit (99342), and vaccines (90471, 90688) provided on October 4, 2018 by out of network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.
You asked the Plan to pre-approve the additional trips. You say that you require additional transportation to get to your chemotherapy treatments. The Plan denied your request. The Plan says you have used up your annual allotment of routine transportation for 2020.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 24 trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveIbrance 100mg capsules.You asked the Plan to pre-approvethe Ibrance capsules. You say that the enrollee meets the criteria for the use of this medication.The Plan denied your request. The Plan says this oral anti-cancer drug is not among those that are covered by 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 oral anti-cancer drug in this case does not have an injectable form. As it is oral-only, it is not covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approveIbrance 100mg capsules.Benefits for the Ibrance capsulesmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit (99213) to be provided by out of network provider.
You asked the Plan to pre-approve an office visit. You say that the other doctor is trained for this injury. The doctor you requested is out-of-network for your physical therapy. You have had relief from the other therapist you are requesting. The Plan denied your request. The Plan says the following must be met for you to use an out-of-network provider: you must have a medical problem that needs urgent or emergency attention, you must have special needs or medical problems and a doctor in the network cannot care for you, and you must live too far away from doctors in your network that are able to care for you.
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 pre-approved care. The requested provider in this case is not a network provider with the Plan. The record shows that during your last visit, you showed improvement with your mobility. 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 these items/services. Therefore, we decided that the Plan does not have to pre-approve an office visit (99213) to be provided by out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650) provided to the enrollee on August 20, 2019.You asked the Plan to pay forthe orthosis. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan must followMedicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650) provided to the enrollee on August 20, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglasses providedon May 10, 2019.You asked the Plan to pay for the eyeglasses. The Plan denied your request. The Plan says you must use a network provider.Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. ThePlan covers these services when provided by a network optical provider.We looked at thefile and the Plan's rules. "the doctor" is not a network optical provider. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for eyeglasses providedon May 10, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve arch support slippers.
You asked the Plan to pre-approve arch support slippers. You say that your doctor recommends this footwear and you cannot afford it on your own. The Plan denied your request. The Plan says this item is not covered by Medicare or the Plan.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve arch support slippers.
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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.
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 is with a diagnosis of dementia and repeated falls. The enrollee discharged from SNF on 1/16/20 to home health on 1/18/20. The recent records indicate the enrollee is hemodynamically stable, and non-toxic. The enrollee is afebrile and has fair dynamic standing balance with therapy. Functionally, the enrollee is minimal assist overall for transfers, mobility, and gait x 150 foot distances. Records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a lower level of care. Ongoing pain medication and other medication management, skin care, and daily therapy can be provided at a lower level of care. In this case, the enrollee is mostly minimal assist for functional transfers and activities of daily living and a less intensive, longer duration of therapy can allow for measurable gains to be attained within a predicted period. 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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the psychiatric evaluation provided on May 15, 2019.You asked the Plan to waive the copayment forthe psychiatric evaluation. You say that you were told you would only have copayments when you met with the doctor. 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $40 copayment for counseling services (group and individual). The enrollee has been asked to pay a $40 copayment for the psychiatric evaluation. The psychiatric evaluation falls within the "Outpatient rehabilitation services" benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does nothave to waive the copayment forthe psychiatric evaluation provided on May 15, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the chemotherapy drugs provided from August 23, 2019 to September 13, 2019.
You asked the Plan to waive the coinsurance for the chemotherapy drugs. You say that this should be covered because it is so expensive and you cannot afford this 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, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for Medicare Part B chemotherapy drugs, associated administration services and all other Medicare Part B drugs. You have been asked to pay $1,879.29 which is 20% of the allowed amount for the chemotherapy drugs for each date of service. The allowed amount is $9,396.44. ($9,396.44 x 20% = $1,879.29). ($1,879.29 + $1,879.29 = $3,758.58). The chemotherapy drugs fall within the "Medicare Part B prescription drugs" 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 chemotherapy drugs provided August 23, 2019 to September 13, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that the enrollee's problems will not be fixed as an outpatient. The Plan denied your request. The Plan says the enrollee does not require physician care at least three times per week, or services performed by a specially trained therapist three hours a day.
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 physician reviewer found that the enrollee is independent for sitting up, standing up, and sitting down. He is at a supervision level for ambulation. He is at standby assist for grooming, lower body dressing, and toileting. The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. 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 for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a Golimumab injection (J1602) and administration (96365) provided on September 26, 2019.
You asked the Plan to waive the copayment for the injection and administration. You say that you were told you would have a $35 copayment for the service provided. The Plan denied your request. The Plan says per the 2019 EOC, the claim processed correctly and assessed the correct cost share.
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 $35 copayment for Medicare Part B Prescription Drugs and $250 copayment for outpatient hospital services. You have been asked to pay a $35 copayment for Medicare Part B Prescription Drug and a $250 copayment for the administration performed in an outpatient hospital. The injection and administration fall within the Medicare Part B Prescription Drugs and Outpatient Surgery benefit categories. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a Golimumab injection (J1602) and administration (96365) provided on September 26, 2019.
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 the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH 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 admission to a LTACH is not medically necessary. Our physician reviewer found based on the documentation provided, the enrollee is currently undergoing treatment at an acute care hospital (ACH) following redo mitral valve surgery. The enrollee was intubated/ventilated for surgery on 1/13 and subsequently received a tracheotomy on 1/22. As of 1/28, the enrollee was progressing with ventilator weaning. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E06521, E0667) provided
to the enrollee on July 22, 2019.
You asked the Plan to pay for the pneumatic compression device. You say that the claim should be paid. The
Plan denied your request. The Plan says the billed supply code cannot be verified.
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 physician order and 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. There is no proof of delivery for the date of service in question. Therefore, we
decided that the Plan does not have to pay for a pneumatic compression device (E06521, E0667) provided to
the enrollee on July 22, 2019.