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

We decided that the Plan does not have to waive the copayment for the colonoscopy provided on November 13, 2019. You asked the Plan to waive the copayment for the colonoscopy. You say that you have never had a large copayment for a colonoscopy before. You say that this is no different than any colonoscopy you've had. 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 $350 copayment per date of service for outpatient surgery at an outpatient hospital facility. You have been asked to pay a $350 copayment for the colonoscopy. The colonoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show that a diagnostic colonoscopy was performed. 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 colonoscopy provided on November 13, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics provided on August 30, 2018.
You asked the Plan to pay for foot orthotics. You say that you desperately need to wear orthotics to be able to
stand any length of time and cannot afford them. The Plan denied your request. The Plan says this item is not a
covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics provided 
on August 30, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prodigy Autocode Test Strips (A4253). You asked the Plan to pre-approve Prodigy Autocode Test Strips. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says they have approved a 3 month supply with no refills for the requested Prodigy Autocode Test Strips to help transition to a preferred brand covered by the Plan. The Plan must follow Medicare rules. The rules say that a Medicare Health Plan must disclose to its members the benefits offered under the plan including applicable conditions and limitations. We looked at the file, the Plan's contract and Medicare rules. The Plan contract clearly states alternate non-preferred brand diabetic supply products are not covered unless a doctor provides adequate information that the use of an alternate brand is medically necessary in the enrollee's specific situation. The file does not provide documentation from your treating physician that the requested non-preferred brand, Prodigy Autocode test strips are medically necessary. Based on this information, we decided that Medicare rules for coverage of Prodigy Autocode Test Strips have not been met. Therefore, we decided that the Plan does not have to pre-approve
Prodigy Autocode Test Strips (A4253).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tier exception for Brovana 15mcg/2ml solution
(J7605).
You asked the Plan to pre-approve a tier exception for Brovana 15mcg/2ml solution. You say that the
exception is needed. The Plan denied your request. The Plan says Part B medications do not qualify for tier
exceptions.
The Plan must follow Medicare rules. Medicare rules say that tiered cost-sharing means a process of grouping
Part D drugs into different cost sharing levels within a Part D sponsor's formulary.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of a tier exception for Brovana 15mcg/2ml solution have not been met. Specifically, the requested
drug is covered under Medicare Part B. This means that it is not eligible for a tier exception, as Medicare Part
B Drugs are not subject to tier exceptions. Therefore, we decided that the Plan does not have to pre-approve a
tier exception for Brovana 15mcg/2ml solution (J7605).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on April 4, 2019 to April 11,
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 there are in-network providers available for these services. The Plan says that no prior authorization was obtained. 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 April 4, 2019 to April 11, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99213) and therapeutic activities (97530) provided on September 3, 2019. You asked the Plan to pay for the office visit and therapeutic activities. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says these services are not manipulation of the spine and are not covered under Medicare or the Plan. The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for an office visit (99213) and therapeutic activities (97530) provided on September 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on March 29, 2019 by an out of network (OON) provider.
You asked the Plan to pay for physician services. You say that you were unaware that the member had an HMO plan until the services were denied. The Plan denied your request. The Plan says no prior authorization was obtained for these 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 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 March 29, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the CPAP provided on July 14, 2019.
You asked the Plan to waive the coinsurance for the CPAP. The Plan denied your request. The Plan says that you pay 20% of the total amount for services from an in-network provider.
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 (DME). You have been asked to pay a 20% coinsurance for the CPAP. The CPAP falls within the Durable medical equipment and related supplies (DME) 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 CPAP provided on July 14, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the duplex scan provided on March 2, 2018.
You asked the Plan to waive the copayment for the duplex scan. You say that this amount should not be your responsibility because so many months have passed. 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 $100 copayment for Medicare-covered outpatient diagnostic radiology services. You have been asked to pay a $100 copayment for the duplex scan. The duplex scan falls within the "Outpatient diagnostic tests and therapeutic services and 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 copayment for the duplex scan provided on March 2, 2018.
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 IRF admission is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an IRF admission.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the member's medical conditions appear stable. There are no complex wound care needs and no unaddressed medical issues. He does not require medical oversight of his condition at an acute hospital level of care. The member requires physical therapy for mobility and occupational therapy for remaining activities of daily living and adaptive equipment; however, he does not require the intensity of an acute level rehabilitation therapy program. Additionally, the member is limited by debility and the severity of his comorbid medical conditions with a standing tolerance of only one minute. He is unable to fully safely participate in or benefit from the required intensity of an acute rehabilitation therapy program. An intensive rehabilitation therapy program would not significantly impact the member's condition differently compared with therapy provided at a less intense level. The member's care can be appropriately provided at a SNF level. 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: Drugs
Decision: Favorable

We decided that the Plan has to pre-approveGazyva for the enrollee.You asked the Plan to pre-approveGazyva. The Plan denied your request. The Plan says that that citations in the Medicare approved compendia do not support this drug.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 Gazyva. Our reviewer says that Gazyva is medically reasonable and necessary for the enrollee in this case. Patient is at very high risk for deterioration. There is some evidence of the benefit of Gazyva in patients with refractory membranous. Our physician reviewer found that the enrollee's condition meets criteria for coverage of Gazyva.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Gazyva have been met.Therefore, we decided that the Plan has to pre-approveGazyva 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on July 29, 2019.
You asked the Plan to pay for the lab services. You say that the service was only billed once on the date of service. The Plan denied your request. The Plan says duplicate services billed on the same day are not covered.
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 83036 is hemoglobin; glycosylated (A1C). We looked at the file and the rules. The records show that code 83036 was billed by the facility and paid for by the Plan for the date of service at issue. Code 83036 has a professional component/technical component (PC/TC) indicator of 9 which means the concept of a professional/technical component does not apply. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on July 29, 2019.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for drug testing provided from October 8, 2019 to November 5, 2019.
You asked the Plan to pay for drug tests. You say that this testing was deemed medically necessary by the ordering physician, and it was not the responsibility of your laboratory to create a treatment plan or have any contact with the enrollee. The Plan denied your request. The Plan says that the denial of payment for these services is correct, because these tests exceed the maximum covered frequency of 18 tests per year.
The Plan must follow Medicare rules. Medicare rules say that the frequency of presumptive urinary drug testing may be limited to 156 times per year for enrollees with 0 to 90 consecutive days of abstinence or 36 times per year for enrollees with more than 90 consecutive days of abstinence. We looked at the file and Medicare rules. Our review of the rules did not reveal a limitation of 18 tests per year for these services, as cited by the Plan. The Plan has not shown that these tests exceeded the frequency limitation for presumptive urinary drug testing as cited above in the LCD. Based on this information, we decided that Medicare rules for coverage of drug tests have been met. Therefore, we decided that the Plan has to pay for drug testing provided from October 8, 2019 to November 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvesix additional chiropractic manipulative treatments (98941).You asked the Plan to pre-approvethese services. You say that you are requesting a reconsideration of the Plan's denial.The Plan denied your request. The Plan says the current treatment plan appears to be a continuation of maintenance therapy for long-standing chronic conditions. The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance care. We asked our physicianreviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the enrollee does not meet criteria for coverage of additional chiropractic manipulative treatments. Our physician reviewer found that the submitted clinical chart notes reveal mainly complaints in the low back and the back of the neck, with no evidence of a new injury or trauma, flareup or exacerbation, revealing a continuation of prior chiropractic treatment. The chiropractic treatments of January 6, 2020, January 20, 2020 and February 5, 2020 are biweekly treatments and suggest maintenance care. The findings mainly reveal spinal restrictions/subluxations, pain/tenderness and multiple hypertonic muscle spasms. The diagnoses do not require long-term ongoing care or support a new trauma, flareup or exacerbation. There is no evidence of significant changes in complaints, findings and diagnoses, with no evidence that any additional chiropractic treatment will significantly alter the outcome. Since further clinical improvement has not occurred, the chiropractic treatment is then considered maintenance therapy, which is not supported or allowed per Medicare guidelines.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pre-approvesix additional chiropractic manipulative treatments (98941).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for cardiac monitoring provided on November 10, 2019.
You asked the Plan to waive the copayment for cardiac monitoring. You say that you did not see a physician and disagree with the 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 $40 copayment for specialist visits. You received cardiac monitoring on November 10, 2019. Cardiac monitoring is considered a physician service. Therefore, you are responsible to pay the $40 copayment. You have been asked to pay a $40 copayment for cardiac monitoring. Cardiac monitoring 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 cardiac monitoring provided on November 10, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the DME provided on May 25, 2018 by an in-network provider.
You asked the Plan to waive the coinsurance for the DME. You say that you do not feel liable for the services. The Plan denied your request. The Plan says the claim was processed accordingly with your 2018 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received DME provided on May 25, 2018 by an in-network provider. You are asked to pay 20% coinsurance for the DME. 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 DME provided on May 25, 2018 by an in-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient rehabilitation care from May 1, 2019 through May 9, 2019 provided by an in-network provider.
You asked the Plan to waive the copayment for inpatient rehabilitation care. You say that you should not be liable for the cost-share due to not leaving the facility and being readmitted. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file shows that you were admitted on May 1, 2019 and discharged on May 9, 2019. You were asked to pay a $300 copayment per day from May 1, 2019 through May 5, 2019, days 1-5 of your inpatient stay. There were no copayment charges from May 6, 2019, day 6 of your inpatient hospital care until your day of discharge May 9, 2019. Per your contract there is a $300 copayment per day required for days 1-5. Cost-sharing (copayment or coinsurance) applies on the date of admission each time you are admitted or transferred to a specific facility type, including inpatient rehabilitation facilities, inpatient acute care facilities and inpatient psychiatric facilities. 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 inpatient rehabilitation care from May 1, 2019 through May 9, 2019 provided by an in-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 28, 2019 by an out of network (OON) provider.
You asked the Plan to pay for outpatient hospital services. You say that you verified that the enrollee had a different health plan for this date of service and should not be penalized for not obtaining authorization from a plan you had no knowledge of. 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 prior authorization was not obtained.
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 the medical services provided on August 28, 2019 by an out of network (OON) provider.