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

We decided that the Plan does not have to waive the coinsurance forthe Botox injection rendered on January 28, 2020.You asked the Plan to waive the coinsurance forthese services. You say that you should not be charged a coinsurance.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). The enrollee's contract with the Plan clearly says that enrollees must pay 20% of the cost for Part B covered chemotherapy drugs and other Part B covered drugs. Review of the file shows that the enrollee received a Botox injection on January 28, 2020. The enrollee has been asked to pay 20% of the cost for these services. These services fall within the Part B covered chemotherapy drugs and other Part B covered drugs benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance forthe Botox injection rendered on January 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ankle foot orthosis provided on April 17, 2020.You asked the Plan to pay forthe ankle foot orthosis. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not supported by the documentation.The Plan must follow Medicare rules. 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 proof of delivery for the supplies provided in this case. Review of the file shows that the documentation submitted did not include an itemized shipping/billing invoice to indicate thespecific supplies or proof of delivery for the billed date of service. 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 forthe ankle foot orthosis provided on April 17, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ligamentous reconstruction services coded 27427 provided.

You asked the Plan to pay forthe ligamentous reconstruction services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not supported by the documentation.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

In this case, the CPT Code Manual definition of code 27427 is ligamentous reconstruction (augmentation), knee; extra-articular.

We find that CPT code 27427 is not supported in the medical record. Specifically, the documentation submitted did not include documentation of ligamentous reconstruction (augmentation), knee; extra-articular; therefore, the billed service cannot be verified. Based on this information, we decided that Medicare rules for coverage of the ligamentous reconstruction services have not been met.Therefore, we decided that the Plan does not have to pay forthe ligamentous reconstruction services coded 27427 provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share forthe durable medical equipment provided on September 16, 2020.You asked the Plan to waive the cost share forthe services provided. You say that you were advised insulin supplies would be covered at 100%.The Plan denied your request. The Plan says the claim was processed correctly according to the plan 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). Your contract with the Plan clearly says that you must pay a 20% coinsurance for durable medical equipment. You have been asked to pay a 20% coinsurance for the servicesprovided. The services fallwithin the durable medical equipment 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 youenrolled in the Plan.Therefore, we decided that the Plan does not have to waive the cost share forthe durable medical equipment provided on September 16, 2020
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lab testing provided on July 31, 2019.You asked the Plan to pay forthe testing services. The Plan denied your request. The Plan says screening testing is not a Medicare benefit for the diagnoses listed on the claim.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. We decided that the Plan does not have to pay forthe lab testing provided on July 31, 2019.You asked the Plan to pay forthe testing services. The Plan denied your request. The Plan says screening testing is not a Medicare benefit for the diagnoses listed on the claim.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires daily monitoring,
respiratory therapy, and rehab therapy. The Plan denied your request. The Plan says the enrollee's medical
needs are being met in the current acute setting.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
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 LTACH services. Our physician
reviewer found that LTACHs are certified as acute care hospitals, and in general, do not provide clinical
services that are materially different than those of short term acute care hospitals. In this case, ongoing care
needs include neurologic monitoring, seizure precautions, surveillance laboratory studies, tube feeding, and
therapy services. The documentation does not support that the enrollee in this case requires services at the
LTACH that are not available at the acute care hospital where he is currently receiving care. There are no
required medical services identified that are available at the LTACH, that are not available at the current health
care setting being offered by the health plan. Consequently, the requested LTACH services are not medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time.
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 LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe back and knee orthoses provided on January 16, 2019.You asked the Plan to pay forthe orthoses. The Plan denied your request. The Plan says the billed supply codes cannot be verified.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 validphysician order and proof of delivery for the supplies provided in this case. Therecord 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 forthe back and knee orthoses provided on January 16, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional hours of home health aide services per week.
You asked the Plan to pre-approve home health aide services. You say that the home health aide services are
necessary. The Plan denied your request. The Plan says additional home health aide services are not medically
necessary to complete your daily activities.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically
necessary for the enrollee to receive skilled nursing or 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 home health aide services. Our
reviewer says that the service is not medically necessary. Our physician reviewer found you do not require
skilled therapy or skilled nursing services which means you not meet the definition of home health aide
services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of home health aide services have not been met. Therefore, we decided that the
Plan does not have to pre-approve additional hours of home health aide services per week.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for ophthalmological services provided.

You asked the Plan to pay for the ophthalmological services. The Plan denied your request. The Plan says with limited exceptions, while you are a member of our plan you must use network providers to get your medical care and services. The only exceptions are emergencies, urgently needed services when the Plan network is not available (generally, when you are out of the area), out-of-area dialysis services, and cases in which the Plan authorizes use of out-of-network providers 

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 ophthalmological 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 ophthalmological services providED.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe knee orthosis and suspension sleeve provided on July 8, 2020.You asked the Plan to pay forthe knee orthosis (L1833) and suspension sleeve (L2397). You say that the Plan should pay this claim.The Plan denied your request. The Plan says there was no previous claims from this physician.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 proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered. The record shows that the Plan made several attempts to obtain the necessary documentation without success.Therefore, we decided thatthe Plan does not have to pay forthe knee orthosis and suspension sleeve provided on July 8, 2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approveKeytruda (J9271) with zoledronic acid (J3489).You asked the Plan to pre-approveKeytruda with zoledronic acid. You say that the services you are requesting are medically necessary for the enrollee's condition.The Plan denied your request. The Plan says that the enrollee does not meet clinical criteria for coverage.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 with zoledronic acid. Our reviewer says that the services you are requesting are reasonable and medically necessary. Our physician reviewer found the services are supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal.Welooked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda with zoledronic acid have been met.Therefore, we decided that the Plan has to pre-approveKeytruda (J9271) with zoledronic acid (J3489).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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approveinsertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (CPT Code 22869).You asked the Plan to pre-approvethe procedure. You say that this procedure is medically necessary.The Plan denied your request. The Plan says this service is considered experimental and investigational as it is not identified as widely used and generally accepted for the proposed use as reported in nationally recognized peer-reviewed medical literature published in the English language.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 the procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the spacer is experimental. More research is needed to show safety and efficacy. 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 procedure have not been met.Therefore, we decided that the Plan does not have to pre-approveinsertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (CPT Code 22869).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not medically necessary.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 medically necessary. Our physician reviewer found the submitted records show that you received an IRF screening on December 9, 2020. You need assistance with bed mobility and transfers. You walk using a rolling walker. You do not require the intensity of services in an IRF. Specifically, you do not need 15 hours per week of rehabilitative services and regular physician evaluation. The IRF services are not reasonable or medically necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the echocardiography provided on July 17,
2020.
You asked the Plan to waive the copayment for the echocardiography. You say that similar tests previously
performed in a hospital never had a patient responsibility. You say that you were not aware of the $155
copayment. 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 $155
copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a
physician's office or at a freestanding facility.
You have been asked to pay a $155 copayment for the echocardiography. The echocardiography 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 echocardiography provided on July 17, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forthe four x-rays and two complex imaging procedures you had on July 3, 2020.You asked the Plan to waive the copayments forthe x-rays and imaging procedures. You say that you believe the Plan isn't paying enough towards these services.You said that you could have paid less if you just paid cash.The Plan denied your request. The Plan says you were charged these copayments 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 copayment for each standard x-ray service and $125 for other (non-x-ray) radiological diagnostic tests. You have been asked to pay a $20 copayment for each of the four x-rays and a $125 copayment for each of the two imaging procedures. For one of the x-rays and one of the imaging procedures, the allowed amounts are less than your copayment obligations, so you are only responsible for the allowed amounts for those services ($13.25 and $120.84, respectively).This means that you have been asked to pay the correct amounts 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 copayments forthe four x-rays and two complex imaging procedures you had on July 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lumbar sacral orthosis (L0650) and the electrical stimulator supplies (A4595) provided on March 26, 2020.You asked the Plan to pay forthese items. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says the records provided do not support the items 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 recorddoes not contain proof of delivery for the supplies provided in this case. The documentation submitted did not include an invoice or proof of delivery for the billed date of service. The submitted invoice indicates the itemswereshipped on March 5, 2020and delivered on March 7, 2020; however, the billed date of service is March 26, 2020. 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 forthe lumbar sacral orthosis (L0650) and the electrical stimulator supplies (A4595) provided on March 26, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecomplete hand prosthesis, which consists of the terminal device, all articulating digits and motors (L6880).You asked the Plan to pre-approvethe hand prosthesis. You say that you respectfully ask for review of this case and overturn the denial of the myoelectric fingers to restore the enrollee to his previous functional level and ability to complete his basic ADL's.The Plan denied your request. The Plan says the upper limb myoelectric prosthesis with independently articulating digits exceeds the member's need and does not meet the Medicare criteria of reasonable and necessary.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 the hand prosthesis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found The plan has approved a myoelectric prosthesis, an externally powered artificial limb. The documentation is insufficient to support that a complete hand prosthesis, with a terminal device, and all articulating digits and motors is medically reasonable and necessary for the enrollee inthis case.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 hand prosthesis have not been met.Therefore, we decided that the Plan does 
not have to pre-approvecomplete hand prosthesis, which consists of the terminal device, all articulating digits and motors (L6880).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to payadditional reimbursement for physician services provided on June 22, 2020.You asked the Plan to payadditional reimbursement. You say that you do not believe the bills you are getting from the provider are correct. Your appeal and your information to this office indicates you were told not the pay them.The Plan denied your request to provide additional reimbursement. The Plan says the Explanation of Benefits shows that you have no further financial liability for this service. The Plan states that they have paid the provider the Medicare allowable and counseled the provider that you should not be balance billed.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 you should not be balanced billed. The Plans Explanation of Benefits shows you have no further liability. The Plan is not required to pay the provider more than the Medicare allowable. Therefore, we decided that the Plan does not have to payadditional reimbursement for physician services provided on June 22, 2020.