Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to adjustthe copaymentfrom $328 per day to $295 per day, for the inpatient hospital care provided March 26, 2020 to April 3, 2020.You asked the Plan to adjust the copayment. You say that you are requesting a reconsideration of the Plan's denial.The Plan denied your request. The Plan says the copaymenthas been applied correctly to the inpatient hospital careprovided.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 paya $328 copayment per day, for days 1-6 and a $0 copayment per day, for days 7-90, for inpatient hospital care rendered by an in-network provider. You have been asked to paya $1,968 copayment ($328 x 6 days) for inpatient hospital care provided by an in-network provider. 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 adjust the copaymentfrom $328 per day to $295 per day, for the inpatient hospital care provided March 26, 2020 to April 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on February 11, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says that 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.
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 physician's services. 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 physician's services provided on February 11, 2020.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pre-approve 6 Transcranial Magnetic Stimulation (TMS) treatments.
You asked the Plan to pre-approve 6 TMS treatments. You say that the services are necessary. The Plan denied
your request. The Plan says that based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that TMS is reasonable and necessary for up to 30
treatment sessions over a 7-week period followed by 6 treatment sessions for tapering for those in remission.
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 6 TMS treatments. Our reviewer says
that the services are medically necessary. Our physician reviewer found documentation shows the enrollee to
improve with the treatments. This enrollee has been tried on multiple medications without success. Based on
review of the records provided, this enrollee does meet the criteria for continued Repetitive Transcranial
Magnetic Stimulation (rTMS) therapy as he has shown some improvement utilizing this procedure.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of 6 TMS treatments have been met. Therefore, we decided that the Plan has to
pre-approve 6 Transcranial Magnetic Stimulation (TMS) treatments.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided on February 17, 2020 and February 19, 2020.
You asked the Plan to pay for the physical therapy services. The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case and the referring provider are not network providers with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physical therapy services provided on February 17, 2020 and February 19, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) services
rendered on February 8, 2020.
You asked the Plan to waive the copayment for these services. You say that you were advised to return to the
ER. The Plan denied your request. The Plan says the copayment was 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 $120
copayment per visit for Medicare-covered emergency care.
Review of the file shows that you received ER services on February 8, 2020. You have been asked to pay a
$120 copayment for these services. These services fall within the Medicare-covered 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 emergency room (ER) services rendered on
February 8, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for speech therapy services (CPT 92597) provided to the enrollee on February 25, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says it is inappropriate to reimburse this service when billed in a facility setting, as indicated by the place of service 22.
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 92597 is "Audiologic Function Tests." The physician fee schedule gives the denied code an "NA" indicator, which means that this procedure is rarely or never performed in the facility setting. The claim and file shows that this service was rendered in an outpatient hospital. 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 speech therapy services (CPT 92597) provided to the enrollee on February 25, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug test provided on March 21, 2019.
You asked the Plan to pay for the drug test. You say that the claim should be reprocessed and paid. The Plan
denied your request. The Plan says Original Medicare is responsible for payment.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services.
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for the drug test provided on March 21, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the continuous positive airway pressure (CPAP) device supplies rendered on March 18, 2020.
You asked the Plan to waive the coinsurance for these services. You say that you feel you were billed in error. The Plan denied your request. The Plan says the coinsurance was 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 20% coinsurance for durable medical equipment and related supplies.
Review of the file shows that you received CPAP supplies on March 18, 2020. You have been asked to pay a 20% coinsurance for these services. These services fall within the durable medical equipment and related supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the continuous positive airway pressure (CPAP) device supplies rendered on March 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a hoyer lift (E0630).
You asked the Plan to pre-approve a hoyer lift. You say that the hoyer lift is needed because the enrollee is too heavy. The personal aid fell trying to carry the enrollee. The Plan denied your request. The Plan says the criteria for medical necessity for coverage not met.
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 a hoyer lift. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the medical records provided the documentation does not meet the requirements for coverage for medical necessity. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a hoyer lift have not been met. Therefore, we decided that the Plan does not have to pre-approve a hoyer lift (E0630).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for tubing with integrated heating element (A4604) CPAP full face mask (A7030) replacement face mask interface (A7031) positive airway pressure device headgear (A7035) positive airway pressure device filter (A7038) filter, non-disposable (A7039) humidifier, heated, used with positive airway pressure device (E0562) provided July 14, 2019.
You asked the Plan to pay for the CPAP supplies. You say that please reprocess the claim with the attached supporting documentation. 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 does not contain a valid physician order for the supplies provided in this case. The signed submitted order is dated 08/17/19 and the billed date of service for the item is 07/14/19. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for tubing with integrated heating element (A4604) CPAP full face mask (A7030) replacement face mask interface (A7031) positive airway pressure device headgear (A7035) positive airway pressure device filter (A7038) filter, non-disposable (A7039) humidifier, heated, used with positive airway pressure device (E0562) provided July 14, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 panel rendered on January 27, 2020.
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 claim was not billed correctly.
The Plan must follow Medicare rules. The rules say that the Guardant360 panel must be billed with procedure code 81479. The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of codes. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 panel rendered on January 27, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe emergency room (ER) services rendered from November 26, 2019 to November 27, 2019.You asked the Plan to waive the copayment forthese services. You say that you were not in the emergency room on this date.The Plan denied your request. The Plan says the copayment was 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 $90 copayment per emergency room visit. Review of the file shows that you received ER services from November 26, 2019 to November 27, 2019. The medical records confirm that you received services on these dates. You have been asked to pay a $90 copayment for these services. These services fall within the emergency room visit 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 forthe emergency room (ER) services rendered from November 26, 2019 to November 27, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the nuclear stress test rendered on March 9, 2020.You asked thePlan to waive the copayment for these services. You say that you disagree with the charges.The Plan denied your request. The Plan says the copayment was 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 $350 copayment for in-network nuclear medicine services at an outpatient hospital. Review of the file shows that you received a nuclear stress test on March 9, 2020. You have been asked to pay a $350 copayment for these services. These services fall within the in-network nuclear medicine services at an outpatient hospital 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 forthe nuclear stress test rendered on March 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the injection provided on January 29, 2020.
You asked the Plan to waive the copayment for the injection. You say that you have never paid this much for an injection before. You can you do not agree with this amount. 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 $390 copayment for surgery services at an in-network outpatient hospital. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $390 copayment for the injection.
You have been asked to pay a $253.87 copayment for the injection. The injection falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows that you were billed by the outpatient hospital for the injection.
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 injection provided by on January 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two core buildups, including any pins when required (D2950 x2).You asked the Plan to pre-approve the core buildups. You say that the enrollee needs to have the remaining old filling removed, because there will not be sufficient tooth structure to replace with a new filing.The Plan denied your request. The Plan says this service is not covered.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 pre-approve two core buildups, including any pins when required (D2950 x2).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency care services provided on April 20, 2018.
You asked the Plan to pay for emergency care. You say that you are appealing with supporting documents. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this claim was not submitted within the timely filing limit.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service. The record shows that a claim for emergency care was not filed until January 21, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for emergency care services provided on April 20, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for adjunctive pre-diagnostic test (D0431) provided March 10, 2020.
You asked the Plan to pay for the dental services. You say that you went for a cleaning and you told them that you wanted only what your plan covers and nothing else because the cleaning technician mentioned several things she wanted to do. The Plan denied your request. The Plan says this service is not covered under the plan 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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for adjunctive pre-diagnostic test (D0431) provided March 10, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Carboplatin (J9045), Paclitaxel (J9267), Pembrolizumab (J9271), Dexamethasone (J1100), Emend (J1453), and Aloxi (J2469).You asked the Plan to pre-approve Carboplatin, Paclitaxel, Pembrolizumab, Dexamethasone, Emend, and Aloxi. You say that the medications are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 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 Carboplatin, Paclitaxel, Pembrolizumab, Dexamethasone, Emend, and Aloxi. Our reviewer says that the medications are not medically necessary. Our physician reviewer found the documentation does not support that the medications are medically reasonable and necessary or safe and effective for the enrollee. There has been no molecular testing of the tumor for MSI, PD-L1, or HER2 to guide therapy or determine the most effective therapy.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Carboplatin, Paclitaxel, Pembrolizumab, Dexamethasone, Emend, and Aloxi have not been met.Therefore, we decided that the Plan does not have to pre-approveCarboplatin (J9045), Paclitaxel (J9267), Pembrolizumab (J9271), Dexamethasone (J1100), Emend (J1453), and Aloxi (J2469).
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve Paclitaxel protein-bound particles 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 that this is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 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 medically reasonable and necessary. Our physician reviewer found the Medicare Compendia provide support for off label use of the requested drug for use as a single agent in relapsed small cell lung cancer. The documentation supports that the Paclitaxel is medically reasonable and necessary for the enrollee. The documentation supports that the Paclitaxel is safe and effective 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 the injection have been met. Therefore, we decided that the Plan has to pre-approve Paclitaxel protein-bound particles injection for the enrollee.
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.