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

We decided that the Plan does not have to waive the copayment forthe ambulance transport provided on August 7, 2019.You asked the Plan to waive the copayment fortheambulance transport. You say that you are disputing the cost.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 $230 copayment for each one-way Medicare-covered ground trip.You have been asked to pay a $230 copayment for the ambulance transport. The ambulance transport falls within the "Ambulance Services" benefit category. The records show that you were transported by ambulance to 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 forthe ambulance transport provided on August 7, 2019
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from March 16, 2018 through April 3, 2018.
You asked the Plan to waive the copayment for the inpatient stay. You say that it is your understanding that there is a zero balance for this stay. You say that the statement should reflect that. 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). The enrollee's contract with the Plan clearly says that enrollees must pay $400 per stay for each in-network medically necessary covered inpatient stay. The enrollee has been asked to pay a $400 copayment for the inpatient stay. The inpatient stay falls within the "Inpatient hospital care" 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 not have to waive the copayment for the inpatient stay provided from March 16, 2018 through April 3, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit and an x-ray provided on April 16, 2019 by out of network provider. You asked the Plan to pay foran office visit and an x-ray. You say that these services were medically necessary.The Plan denied your request. The Plan says there is no valid referral on file for this service.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 foran office visit and an x-ray provided on April 16, 2019 by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the abdominal paracentesis provided on August 22, 2019.
You asked the Plan to waive the copayment for the abdominal paracentesis. You say that the hospital should have taken you when you went into the emergency room. You say that the copayment should be waived. 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 $200 for each in-network, Medicare-covered outpatient hospital facility visit. You have been asked to pay a $200 copayment for the abdominal paracentesis. The abdominal paracentesis 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 abdominal paracentesis provided on August 22, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services provided on August 22, 2019 by the out of network provider.You asked the Plan to pay forthe ambulance services. You say that the service was medically necessary.The Plan denied your request. The Plan says you did not request prior authorization.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan 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 forthe ambulance services provided on August 22, 2019 by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forthe office visits provided on May 15, 2019 and May 21, 2019.You asked the Plan to waive the copayments forthe office visits. You say that you were not provided any services. You say that there should be a refund.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 $40 copayment for services obtained from a specialist. You have been asked to pay a $40 copayment for each office visit. The total amount you owe is $80 ($40/visit x 2 visits = $80). The office visits fall within the "Physician/Practitioner Services, Including Doctor's Office Visits" benefitcategory. 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 forthe office visits provided on May 15, 2019 and May 21, 2019
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp injection 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 there is no medical necessity for a step therapy exception.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the injection. Our reviewer says that the requested injection is not medically reasonable or necessary. Our physician reviewer found the provided medical records do not indicate that the enrollee has tried and failed Retacrit. The provided medical records do not indicate that the Plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee. Review of the FDA Drug Shortages Database indicates no shortage of the drug Retacrit. 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 not been met. Therefore, we decided that the Plan does not have to pre-approve Aranesp injection for the enrollee.
Appeal type: Lab
Decision: Partially Favorable

We decided that the Plan has to waive the copayment for the therapeutic injection. We decided that the Plan does not have to waive the coinsurance for the denosumab injection.
You asked the Plan to waive the cost share for the denosumab injection and its injection. You say that you have never been charged this amount before. The Plan says that you have been charged the correct cost sharing amount.
We decided that the Plan has to waive the copayment for the therapeutic injection.
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles, and coinsurance). The records show that therapeutic injection is considered a physician service. Your plan contract clearly says that you pay a $0 copayment for provider and professional services at an in-network outpatient hospital.
The Plan says that you must pay a $52.58 copayment for the therapeutic injection. Based on the plan contract, however, you cannot be asked to pay more than a $0 copayment for the therapeutic injection. Therefore, we decided that the Plan has to reduce the copayment for the therapeutic injection from a $52.58 copayment to a $0 copayment.
We also decided that the Plan does not have to waive the coinsurance for the denosumab injection.
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 chemotherapy drugs at an in-network outpatient hospital. You have been asked to pay $335.23 which is 20% of the allowed amount for the denosumab injection. The allowed amount is $1,676.16. ($1,676.16 x 20% = $335.23). Therefore, we decided that the Plan does not have to waive the coinsurance for the denosumab injection.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rituxan for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your
request. The Plan says the off-label use of this drug is not medically accepted.
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 the drug. Our reviewer says that the
requested drug is not medically necessary. Our physician reviewer found Rituxan is not FDA approved for the
requested diagnosis. None of the CMS approved compendia support the requested use. The 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 the drug have not been met. Therefore, we decided that the Plan does not have
to pre-approve Rituxan for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve services to be to be provided by out of network provider
You asked the Plan to pre-approve these out-of-network services to be provided at the in-network benefit level. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services can be provided by a network provider.
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 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. We note that you may receive services from this out-of-network provider, however, your cost share amounts will be higher. Therefore, we decided that the Plan does not have to pre-approve services
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says this 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 based on the medical records provided, the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment in an intensive rehabilitation therapy program. You may not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ajovy injection (J3490).
You asked the Plan to pre-approve the Ajovy. You say that you would like reconsideration as this drug has significantly improved the member's condition. The Plan denied your request. The Plan says Ajovy is self-administered at home and not covered under the member's Medicare Part A or 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 Ajovy injection (J3490).
Benefits for the Ajovy 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a white tip cane.
You asked the Plan to pre-approve the cane. You say that this is medically necessary. The Plan denied your
request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
A white cane is not covered, as it does not serve a primarily medical purpose. Therefore, we decided that the
Plan does not have to pre-approve a white tip cane.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve community-based adult services (S5102).
You asked the Plan to pre-approve the community-based adult services. You say that these services are necessary for the member and their provider recommended the out-of-network provider. The Plan denied your request. The Plan says no medical reason has been established to warrant an out-of-network referral for these services.
The Plan must follow Medicare rules. The rules say that custodial care is not covered. We looked at your request, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the community-based adult services have not been met. Specifically, community-based adult services are not a Medicare covered benefit. Therefore, we decided that the Plan does not have to pre-approve community-based adult services (S5102).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cleaning device for your CPAP (A9270).
You asked the Plan to pre-approve the CPAP cleaning device. You say that you can get an infection from not having a system to clean your CPAP device. The Plan denied your request. The Plan says the cleaning device is not a Medicare covered service.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a cleaning device for your CPAP (A9270).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says medically necessary care is 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 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. 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 a referral to an out-of-network provider.
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-approvethese 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. 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee's ongoing care needs include tracheostomy care with ventilator support and weaning, neurologic monitoring, surveillance laboratory studies, tube feedings, intravenous antibiotics, and therapy services. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary,reasonable, and appropriate for the diagnosis and condition of the enrollee 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 these 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the coinsurance for the prostatectomy provided on September 18, 2019.
You asked the Plan to reduce the coinsurance for the prostatectomy. You say that your approval letter did not state that the charges would be higher if you used an out-of-network facility, only if you used an out-of-network provider. You say you should be charged the in-network rate. 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 50% coinsurance for out-of-network Medicare-covered outpatient surgery. You have been asked to pay a total coinsurance amount of $4,830.80 which is 50% of the total allowed amount for the prostatectomy. The total allowed amount is $9,661.58. ($9,661.58 x 50% = $4,830.80). The record shows the hospital is out-of-network.
The prostatectomy falls within the out-of-network Medicare-covered outpatient surgery 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 reduce the coinsurance for the prostatectomy provided on September 18, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for an electroencephalogram (95822) provided June 13, 2019.
You asked the Plan to pay for an electroencephalogram. You say that the services provided were medically
necessary. The Plan denied your request. The Plan says the billed code is not supported for payment.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
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 an electroencephalogram. Our reviewer says
that the billed code is not supported in the medical records. Our physician reviewer found the medical records
provided do not include documentation of an electroencephalogram; recording in coma or sleep only, therefore
CPT code 95822 cannot be verified.
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 electroencephalogram have not been met. Therefore, we decided that the
Plan does not have to pay for an electroencephalogram (95822) provided June 13, 2019.