Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment for an office visit provided on November 7, 2019.
You asked the Plan to waive the copayment for an office visit. You say that you disagree with the charges. The Plan denied your request. The Plan says that 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. Your contract with the Plan says that enrollees must pay a $0 copayment for physician/practitioner services, including doctor's office visits. The Plan says you must pay a $41 copayment for an office visit. Based on the Plan contract, however, you cannot be asked to pay more than a $0 copayment for an office visit. Therefore, we decided that the Plan has to waive the copayment for an office visit provided on November 7, 2019.
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: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe emergency room visit provided on November 12, 2019.You asked the Plan to waive the copayment forthe emergency room visit. You say that this visit should be considered a follow-up and should not apply the 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 a $90 copayment for each emergency roomvisit. You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls within the "Emergency Care" benefit category. Please note, there is no provision in the contract which indicates a copayment would be waived if performed as a follow-up to previous emergency room visit.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 emergency room visit provided on November 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee on September 30, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. You say that the charges are supported based on documentation. The Plan denied your request. The Plan says the enrollee's plan requires utilization of network providers, and authorization for certain services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these OON services. Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee on September 30, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve DUPIXENT.
You asked the Plan to pre-approve the DUPIXENT. You say that you would like reconsideration because this drug is medically necessary for the treatment of the member's condition. The Plan denied your request. The Plan says DUPIXENT is intended for patient self-administration and 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 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 DUPIXENT.
Benefits for the DUPIXENT 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says that the information submitted does not demonstrate that the enrollee requires daily skilled nursing care for at least one hour of skilled therapy per day for at least 5 days per week as required by Medicare criteria.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for sterile collagen dressing (A6021) Alginate dressing (A6196) sterile foam dressing, without adhesive border (A6210) non-sterile gauze (A6216) provided April 7, 2019.
You asked the Plan to pay for the surgical dressings. You say that kindly send the claim back for reprocessing. The Plan denied your request. The Plan says the records provided do not support the service billed.
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 the proof of delivery for the supplies provided in this case. Therefore, we decided that the Plan does not have to pay for sterile collagen dressing (A6021) Alginate dressing (A6196) sterile foam dressing, without adhesive border (A6210) non-sterile gauze (A6216) provided April 7, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the endoscopy provided on November 22, 2019.
You asked the Plan to waive the copayment for the endoscopy. You say that you have never had to pay this before. You say that you don't understand why you have to pay it now. 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 $150 per day for outpatient procedures and services, including but not limited to diagnostic and therapeutic endoscopy, and outpatient surgery performed in an outpatient hospital or ambulatory surgical center.
You have been asked to pay a $150 copayment for the endoscopy. The endoscopy 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 endoscopy provided on November 22, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Cetuximab for enrollee.You asked the Plan to pre-approve Cetuximab. The Plan denied your request. The Plan says the use of Cetuximab as monotherapy for treatment of anal cancer is not supported.The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Cetuximab. Our physician reviewer found that the enrollee has metastatic anal cancer. The requested use of Cetuximab is not FDA-approved for the enrollee's diagnosis. The use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. There is limited data to support single-agent use. Therefore, the requested drug is not 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 Cetuximab have not been met. Therefore, we decided that the Plan does not have to pre-approve Cetuximab for enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on January 8, 2020.
You asked the Plan to waive the copayment for the ambulance transport. You say that this should be waived because you wanted to have your husband drive you instead of taking an ambulance. The Plan denied your request. The Plan says that the claim processed 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 $200 copayment for each one-way Medicare-covered trip. You have been asked to pay a $200 copayment for the ambulance transport. The ambulance transport falls within the one-way Medicare-covered trip 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 ambulance transport provided on January 8, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the 3D rendering with interpretation and reporting services provided on November 15, 2019.
You asked the Plan to pay for the 3D rendering with interpretation and reporting services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 76377 is 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision; requiring image postprocessing on an independent workstation. We find that CPT code 76377 is not supported in the medical record. Specifically, the documentation submitted did not include documentation of 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision; requiring image postprocessing on an independent workstation; therefore, the billed service cannot be verified. Based on this information, we decided that Medicare rules for coverage of the 3D rendering with interpretation and reporting services have not been met. Therefore, we decided that the Plan does not have to pay for the 3D rendering with interpretation and reporting services provided on November 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the special pump services rendered to the enrollee on November 18, 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 the services are not covered.
The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of X are statutorily excluded. The provider submitted a claim for procedure code 99190 (special pump services). This code has a status indicator of X and no separate Medicare payment. Payment is included in the payment to the facility. Therefore, we decided that the Plan does not have to pay for the special pump services rendered on November 18, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on October 15, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on October 15, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the left, lower quadrant alveoloplasty (D7311).
You asked the Plan to pre-approve the left, lower quadrant alveoloplasty (D7311) . You say that tooth #20 and #1 need to be extracted. You say after the extractions; the member needs the alveoplasty for future dentures. The Plan denied your request. The Plan says the service is not covered benefits.
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 left, lower quadrant alveoloplasty (D7311) is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the left, lower quadrant alveoloplasty (D7311).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a computed tomographic (CT) angiography of the abdominal arteries (75635), regadenoson injection (J2785), and normal saline solution infusion (J7040) provided from October 4, 2019 to October 12, 2019.
You asked the Plan to waive the copayment for the CT angiography of the abdominal arteries, regadenoson injection, and normal saline solution infusion. You say that you should not be responsible for the copayments since you were not advised of the cost of the services in advance. The Plan denied your request. The Plan says based on Medicare billing criteria, the claims were billed correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Medicare Part B prescription drugs and a $180 copayment for advanced imaging services. You have been asked to pay $220.48 for the CT angiography of the abdominal arteries, regadenoson injection, and normal saline solution infusion. $40.27(20% of the allowed amount $201.36) plus $.21(20% of the allowed amount $1.03) plus $180 equals $220.48. 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 computed tomographic (CT) angiography of the abdominal arteries (75635), regadenoson injection (J2785), and normal saline solution infusion (J7040) provided from October 4, 2019 to October 12, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the endoscopy provided on October 4, 2019.
You asked the Plan to waive the copayment for the endoscopy. You say that you were informed you were covered for both procedures. 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 $0 copayment for any surgical procedures (polyp removal) during a colorectal cancer screening and a $125 copayment for all other ambulatory surgical center services. You have been asked to pay a $125 copayment for the endoscopy. The endoscopy 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 endoscopy provided on October 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the special pump services rendered on November 15, 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 the services are not covered.
The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of X are statutorily excluded. The provider submitted a claim for procedure code 99190 (special pump services). This code has a status indicator of X and no separate Medicare payment. Payment is included in the payment to the facility. Therefore, we decided that the Plan does not have to pay for the special pump services rendered on November 15, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable control system, 3 swing away control interface, a malleable calf panel, and power seat elevation feature for your power wheelchair.You asked the Plan to pre-approve the denied items. The Plan denied your request. The Plan says the requested items are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that power wheelchair options are only covered under certain medical indications. The file shows that a power seat elevation feature was requested. We looked at the file and the rules. The feature is non-covered because they are not primarily medical in nature.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 denied items. Our physician reviewer found that you are able to perform activities of daily living at a wheelchair level.  Therefore, your upper extremity function should be adequate to control the power options through their own individual switches. An expandable controller is not needed to operate3 or more powered seating actuators through the drive control.Per documentation,the E1028 swing aways were already approved and additional items are not necessary as this would be duplicative. The one-piecemalleable calf panel is not necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member.Therefore, the requested expandable control system, swing aways, and calf panel are not medically reasonable and necessary for the power wheelchair.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 denied items have not been met.Therefore, we decided that the Plan does not have to pre-approvean expandable control system, 3 swingaway control interface, a malleable calf panel, and power seat elevation feature for your power wheelchair.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to reimburse you for the moderate general anesthesia (D9239) provided on December 2, 2019.
You asked the Plan to reimburse you for the dental service. You say that due to your age and the location of the teeth that needed to be extracted, your dentist advised you should have IV sedation. You say that you were expecting at least some of the cost to be covered. The Plan denied your request. The Plan says that the general anesthesia was not medically necessary.
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. The Plan covers the dental service when the services are medically necessary and reasonable. 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 reimburse you for the dental service. Our reviewer says that the service is medically necessary. Our physician reviewer found the documentation provided indicates you are an elderly male with underlying medical conditions. The oral surgeon indicates that the needed extractions should be performed with moderate sedation due to your medical history. The reviewer finds that the surgeon is in the best position to evaluate and determine your status and treat in the manner they feel is best for you. The reviewer therefore finds that the general anesthesia is medically reasonable and necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental service have been met. Therefore, we decided that the Plan has to reimburse you for the moderate general anesthesia (D9239) provided on December 2, 2019.
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.