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

We decided that the Plan does not have to pre-approve a tier exception for Novolog.
You asked the Plan to pre-approve a tier exception. The Plan denied your request. The Plan says that tiering is only available for Part D drugs.
The Plan must follow Medicare rules. Medicare rules say that tier exceptions are only available for Part D drugs. The requested drug is covered under Part B. Based on this information, we decided that Medicare rules for coverage of a tier exception have not been met. Therefore, we decided that the Plan does not have to pre-approve a tier exception for Novolog.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the SPECT test provided on October 3, 2019.
You asked the Plan to waive the copayment for the SPECT test. You say that this service should be covered by your insurance. You say you had this test in 2015 and the insurance paid for everything. 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 for nuclear medicine services at an in-network outpatient hospital. You have been asked to pay a $300 copayment for the SPECT test. The SPECT test falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows you were billed for the SPECT test.
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 SPECT test provided on October 3, 2019.
Our decision is only about the 2019 service. If you have any questions about prior years billing, please contact the plan directly.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four monitoring (95999) provided on February 21, 2019.
You asked the Plan to pay for the train of four monitoring. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says train of four is considered integral to the primary procedure, neurophysiology monitoring and therefore is part of a bundled 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 find that CPT code 95999 is not supported in the record. Specifically, train of four monitoring is part of a bundled payment with the approved neuromonitoring service. Train of four monitoring is not separately payable. Based on this information, we decided that Medicare rules for coverage of the train of four monitoring have not been met. Therefore, we decided that the Plan does not have to pay for train of four monitoring (95999) provided on February 21, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy, implanted pump pain management infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (S9328) provided to the enrollee from April 4, 2019 to July 9, 2019.
You asked the Plan to pay for these services. The Plan denied your request. The Plan says that this is not covered by Medicare.
The Plan must follow Medicare rules. The rules say that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies. You are billing for home infusion services S9328. This is not a valid code for Medicare purposes and the plan does not offer an additional benefit for this service. Therefore, we decided that the Plan does not have to pay for the home infusion therapy, implanted pump pain management infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (S9328) provided to the enrollee from April 4, 2019 to July 9, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient hospital services for knee surgery.
You asked the Plan to pre-approve inpatient services. You say that the doctor would like you to stay an extra day. The Plan denied your request. The Plan says there are no complex medical needs that put you at risk of adverse events.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 services. Our physician reviewer found that you have no serious medical conditions that would necessitate an inpatient hospitalization. The record does not show that the enrollee's care will span two midnights. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient hospital services for knee surgery.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection of sclerosant for spider veins (36468) provided on July 8, 2019.
You asked the Plan to pay for the spider vein treatment. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this service does not meet the coverage requirements in the applicable Local Coverage Determination or National Coverage Determination.
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are coverable.
We looked at your request, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the spider vein treatment have not been met. Specifically, per Medicare, treatment of telangiectases (CPT code 36468), is considered cosmetic and not a covered benefit. Therefore, we decided that the Plan does not have to pay for the injection of sclerosant for spider veins (36468) provided on July 8, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from December 28, 2018 to January 8, 2019.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that this was a continuation of care and you disagree with the second inpatient copayment. 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 $325 copayment per day for days 1-5 for inpatient hospital care. Your inpatient cost share will begin on day one each time you are admitted or transferred to inpatient facilities. The record shows that you were transferred to the facility from December 28, 2018 to January 8, 2019. This is considered a new inpatient hospital admission. Therefore, you are responsible to pay a $325 copayment for days 1-5 (December 28, 2018 to January 1, 2019). $325 (copayment) x 5 (inpatient days) = $1,625.00. You have been asked to pay the total copayment amount of $1,625.00 for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital 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 an inpatient hospital stay provided from December 28, 2018 to January 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urgent care visit provided on September 27, 2019.
You asked the Plan to waive the copayment for the urgent care visit. You say that you should not be responsible for the copayment because if your provider had been available you would not have needed to go to urgent care. 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 $50 copayment for each urgently needed care visit. You have been asked to pay a $50 copayment for the urgent care visit. The urgent care visit falls within the "Urgently needed services" benefit category. The record shows you were seen at an urgent care facility.
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 urgent care visit provided on September 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on May 31, 2019 by an out of network (OON) provider.
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained for the services that were provided.
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 for physician services provided on May 31, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a SoClean sanitizing machine.
You asked the Plan to pre-approve the requested item. You say that there is no way the CPAP machine can be cleaned without it. The Plan denied your request. The Plan says routine maintenance of durable medical equipment is not covered.
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 SoClean sanitizing machine.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the mental health care visit provided on October 15, 2019.
You asked the Plan to waive the copayment for the mental health care visit. You say that you are being overcharged for this visit. 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 $40 copayment for each in-network Medicare-covered individual therapy session. You have been asked to pay a $40 copayment for the mental health care visit. The mental health care visit falls within the "Outpatient Mental Health 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 mental health care visit provided on October 15, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the facet joint injection and facet joint destruction provided on July 8, 2019 and August 26, 2019.
You asked the Plan to waive the copayment for the facet joint injection and facet joint destruction. You say that the shots were necessary. You say that you are unable to pay. 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 $395 copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges.
You have been asked to pay a total of $790 for the facet joint injection and facet joint destruction.
Date of Service
Service
Standard Copayment
Member Liability
July 8, 2019
Facet Joint Injection
$395
$395
August 26, 2019
Facet Joint Destruction
$395
$395
TOTAL:
$790
The facet joint injection and facet joint destruction fall within the "Outpatient Surgery and Other Medical 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 facet joint injection and facet joint destruction provided on July 8, 2019 and August 26, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the duplex scan provided on October 7, 2019.
You asked the Plan to waive the copayment for the duplex scan. You say that the service was performed in the doctor's office and not at the hospital. You say you were charged twice by the provider and the hospital. 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 $20 copayment for Medicare-covered outpatient diagnostic procedures or tests. You have been asked to pay a $20 copayment for the duplex scan. The duplex scan falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows you were billed separately by 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 for the duplex scan provided on October 7, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Churchill car seat harness for the enrollee.
You asked the Plan to pre-approve the requested item. You say that the enrollee need's the equipment for quality care of life. The Plan denied your request. The Plan says items that are not medical in nature cannot be approved.
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 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 Churchill car seat harness for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for cinacalcet provided from January 1, 2019 through February 27, 2019.
You asked the Plan to waive the coinsurance for cinacalcet. You say that you have never received this medication. You say that you will not be paying. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for each Medicare-covered Part B drug. You have been asked to pay $505.54, which is less than the standard 20% coinsurance for cinacalcet because you met your maximum out-of-pocket. Cinacalcet falls within the "Medicare Part B Prescription Drugs" benefit category. The records show that cinacalcet was provided. 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 cinacalcet provided from January 1, 2019 through February 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve nine office visits to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve nine out-of-network office visits. You say that you want to see this doctor due to your dizziness. The Plan denied your request. The Plan says these services are 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 care that cannot be provided by network providers. 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 nine office visits to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the hospital facility and anesthesia fees for dental care in an ASC setting in an OON facility.
You asked the Plan to pre-approve hospital facility and anesthesia fees. You say that the enrollee has avoided dental care because previous offices have not been able to provide the level of sedation that he needs to be compliant to successfully and safely have his care completed. You also say that you have established positive and satisfactory dental treatment and experiences with the enrollee. The Plan denied your request. The Plan says these services are available to the enrollee within the Plan's 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 care that cannot be provided by network providers. 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 the hospital facility and anesthesia fees for dental care in an ASC setting in an OON facility.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Xifaxan 550 mg tablet medication.
You asked the Plan to pre-approve this medication. You say that this medication is medically necessary for your patient. The Plan denied your request. The Plan says this medication is not a covered benefit under the member's contractual policy.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve the Xifaxan 550 mg tablet medication.
Benefits for this medication 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: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on September 10, 2019.
You asked the Plan to waive the copayment for the emergency room visit. You say that the Plan advertisements say that there are no copayments for hospital visits. You say you would like the copayment removed. 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 room visit. 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. 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 visit provided on September 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on April 8, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says there is no valid referral 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 did not pre-approve the service 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 physician's services provided on April 8, 2019.