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

We decided that the Plan does not have to pay for the subsequent hospital care services coded 99232 provided on October 5, 2020.
You asked the Plan to pay for the subsequent hospital care 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 payable.
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 99232 is subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is responding inadequately to therapy or has developed a minor complication. Typically, 25 minutes are spent at the bedside and on the patient's hospital floor or unit. We find that CPT code 99232 is not supported in the medical record. Specifically, another claim by another provider for the same date of service and within the same group with the same specialty was already billed and processed by the plan. This service exceeds the maximum allowable units per date of service. Based on this information, we decided that Medicare rules for coverage of the subsequent hospital care services have not been met. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care services coded 99232 provided on October 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient diagnostic test provided by a participating provider on September 25, 2020.
You asked the Plan to waive the copayment for an outpatient diagnostic test. You say that you do not agree with this copayment. The Plan denied your request. The Plan says the correct copayment has been applied.
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 $30 copayment for outpatient diagnostic tests/non-radiological diagnostic services. You have been asked to pay a $30 copayment for an outpatient diagnostic test. The correct copayment has been applied to the services that were provided. An outpatient diagnostic test falls within the outpatient diagnostic tests/non-radiological diagnostic services 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 an outpatient diagnostic test provided by a participating provider on September 25, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve inpatient admission for spinal surgery for the enrollee.
You asked the Plan to pre-approve inpatient admission for spinal surgery. You say that inpatient admission is medically necessary. The Plan denied your request. The Plan says that while the surgery was approved, inpatient admission prior is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that inpatient admission is covered when determined to be medically 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 inpatient admission for spinal surgery. Our reviewer says that inpatient admission is medically necessary. Our physician reviewer found the enrollee has a fracture above a previous fusion with kyphosis and stenosis. The enrollee needs an extensive multilevel spinal fusion procedure. Inpatient surgery is the standard of care for this procedure. The risk of complications is too high with outpatient or observational stay. Medicare coverage criteria are met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient admission for spinal surgery have been met. Therefore, we decided that the Plan has to pre-approve inpatient admission for spinal surgery 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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye exam (92014) provided on September 23, 2020 by an out of network (OON) provider.
You asked the Plan to pay for an eye exam (92014). You say that you do not think you should have to pay. The Plan denied your request. The Plan says you must pay the full amount because you received non-urgent, non-emergent care without prior authorization from an out-of-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 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 had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the eye exam (92014) provided on September 23, 2020 by an out of network (OON) provider.
Your complaint about the care you received in the past with an in-network provider is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 30, 2020 by an out of network (OON) provider.

You asked the Plan to pay for outpatient rehabilitation services. You say that the enrollee was referred by a participating provider, so this should be considered plan-directed care. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and the referring physician is also out-of-network with the Plan.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on October 30, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the Part B injection provided on October 26, 2020.
You asked the Plan to waive the copayment for the Part B injection. You say that you were never informed of any additional cost about the office 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% of the plan-allowed amount for in-network Medicare Part B-covered drugs. You have been asked to pay $$31.92 which is 20% of the allowed amount for the Part B injection. The allowed amount is $159.62. ($159.62 x 20% = $31.92). The Part B injection falls 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 copayment for the Part B injection provided on October 26, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a negative pressure wound therapy electrical pump provided from July 16, 2020, through July 7, 2020.
You asked the Plan to pay for the negative pressure wound therapy electrical pump. The Plan denied your request. The Plan says 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 is not a network provider with the Plan. The Plan did not pre-approve the negative pressure wound therapy electrical pump We found no exception that would require the Plan to pay for this item. Therefore, we decided that the Plan does not have to pay for a negative pressure wound therapy electrical pump provided from July 16, 2020, through July 7, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox injections.
You asked the Plan to pre-approve Botox. You say that the enrollee would benefit from Botox to help with the enrollee's increased tone. The Plan denied your request. The Plan says rules for pre-approval have not been met.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. In this case, the record indicates that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Botox injections.
Benefits for Botox 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda for the enrollee.
You asked the Plan to pre-approve Keytruda. You say that Keytruda is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Keytruda. Our reviewer says that Medicare coverage criteria are not met. Our physician reviewer found the requested drug is not indicated for the treatment of metastatic disease in patients how have progressed after two prior lines of immunotherapy. This use is not FDA approved for this indication or supported by the medical literature or major drug compendia. Medicare coverage criteria are not met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton beam therapy for the enrollee.
You asked the Plan to pre-approve proton beam therapy. You say that this treatment is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
The Plan must follow Medicare rules. Medicare has specific coverage criteria for proton beam therapy. 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 proton beam therapy. Our reviewer says that Medicare coverage criteria are not met. Our physician reviewer found to date, there are no compelling data to suggest that proton therapy is superior to or more beneficial than IMRT or IGRT. The generally accepted standard of care for prostate cancer is to only offer proton beam therapy on clinical trials, and to not routinely offer it to patients. Medicare coverage criteria are not met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of proton beam therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve proton beam therapy for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that an acute inpatient rehabilitation facility admission is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for coverage of an acute inpatient rehabilitation facility admission.
The Plan must follow Medicare rules. The rules say that an 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 that 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. The enrollee's needs can be met at a lower level of care. 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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the observation stay provided on October 18, 2020.

You asked the Plan to waive the copayment for the observation stay. You say that this copayment is difficult to afford. 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 $300 copayment per visit for Medicare-covered outpatient observation services. 

You have been asked to pay a $300 copayment for the observation stay. The observation stay falls within the "Outpatient hospital observations" 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 observation stay provided on October 18, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for radiation oncology treatment provided on August 24, 2020.

You asked the Plan to pay for the radiation oncology treatment. The Plan denied your request. The Plan says
non-emergent, non-urgent services with out-of-network providers require 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 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 radiation oncology treatment provided on August 24, 2020.
Appeal type: Outpatient Therapies
Decision: Partially Favorable

We decided that the Plan has to reduce the copayments for radiology and physical therapy services from a $40 to a $20 copayment. We decided that the Plan does not have to waive the copayments for emergency care services.
You asked the Plan to waive the copayments for radiology services, physical therapy services and emergency care. You say that you would like all copays to be paid by the Plan. The Plan says that you are protected by the state Medicaid office while a member of the Plan and you are not responsible for the copayments.
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 contract with the Plan clearly says there is a $20 copayment for outpatient rehabilitation services and basic radiological services/diagnostic procedures and tests. The contract also clearly says there is a $120 copayment for emergency care. You have been asked to pay a $40 copayment for radiology and physical therapy services and a $90 copayment for emergency care services. According to the Plan contract, you cannot be asked to pay more than a $20 copayment for radiology and physical therapy services and a $90 copayment for emergency care.
This means that the Plan must reduce your cost-share for radiology and physical therapy services. This also means that you have been asked to pay the correct amount/less than the required copayment for emergency care. This cost sharing is a contractual obligation that you agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan has to reduce the copayments for radiology and physical therapy services from a $40 to a $20 copayment. We also decided that the Plan does not have to waive or reduce the copayments for the emergency care services at issue.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Factor V (F5) Leiden and Prothrombin (F2) gene analyses.
You asked the Plan to pre-approve Factor V (F5) Leiden and Prothrombin (F2) gene analyses. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested services.
The Plan must follow Medicare rules. Medicare rules say that genetic testing for the F2 and F5 genes for all risk factors, signs, symptoms, diseases, or conditions, including cardiovascular risk assessment, are non-covered except for pregnant patients. We looked at the file and Medicare rules. Review of the file does not support that the enrollee is pregnant. Based on this information, we decided that Medicare rules for coverage of Factor V (F5) Leiden and Prothrombin (F2) gene analyses have not been met. Therefore, we decided that the Plan does not have to pre-approve Factor V (F5) Leiden and Prothrombin (F2) gene analyses.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug services rendered on September 9, 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 procedure codes J3490, J3411, J3415 and J1955 are not supported.

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 J3490 is unclassified drugs. The definition of code J3411 is injection, thiamine hcl, 100 mg. The definition of code J3415 is injection, pyridoxine hcl, 100 mg. The definition of code J1955 is injection, levocarnitine, per 1 gm. 

We find that CPT codes J3490, J3411, J3415 and J1955 are not supported in the medical record. Specifically, the records show that drug in compounding form was administered and J3490 is not the most appropriate code for these services. The documentation indicates that nutria-pharmaceutical blend was administered; therefore, codes J3411, J3415, and J1955 cannot be billed separately. 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 drug services rendered on September 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided on August 26, 2020.
You asked the Plan to waive the copayment for an office visit. You say that you disagree with the facility charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $15 copayment for each primary care provider visit. You have been asked to pay a $15 copayment for an office visit. An office visit falls within the physician/practitioner services, including doctor's office visits 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 an office visit provided on August 26, 2020.