Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve addition to endoskeletal knee-shin system, fluid stance extension, dampening feature, with or without adjustability (L5848), addition, endoskeletal knee-shin system, single axis, fluid swing and stance phase control (L5828), addition, endoskeletal, knee-shin system, stance flexion feature, adjustable (L5845) and addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing and stance phase, includes electronic sensor(s), any type (L5856) and all lower extremity prostheses, flex foot system (L5980), for the enrollee. 
 
You asked the Plan to pre-approve the items. You say that the member is an excellent candidate for this prosthesis. The Plan denied your request. The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the items have not been met. We cannot approve for the microprocessor knee. This is because you have never worn a prosthesis. Therefore, you cannot be classified as a K3 ambulator. We cannot approve for a microprocessor knee. This is because it is rated for patients at K3 level. You have never worn a prosthesis and cannot be at the K3 level. The flex walk foot is also at the K3 level and not appropriate for you now. Therefore, we decided that the Plan does not have to pre-approve addition to endoskeletal knee-shin system, fluid stance extension, dampening feature, with or without adjustability (L5848), addition, endoskeletal knee-shin system, single axis, fluid swing and stance phase control (L5828), addition, endoskeletal, knee-shin system, stance flexion feature, adjustable (L5845) and addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing and stance phase, includes electronic sensor(s), any type (L5856) and all lower extremity prostheses, flex foot system (L5980), for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider from January 6, 2020 to January 22, 2020. You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized. 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 services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-network provider from January 6, 2020 to January 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code J0280 provided on December 13, 2019.
You asked the Plan to pay for CPT code J0280. You say that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided for each procedure code. We find that 3 units of CPT code J0280 is not supported in the medical record. Each billing of CPT code J0280 is up to 250 mg per injection. The record shows only 75 mg of J0280 was provided, which is considered 1 unit. Based on this information, we decided that Medicare rules for coverage of CPT code J0280 have not been met. Therefore, we decided that the Plan does not have to pay for CPT code J0280 provided on December 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve intradialytic parenteral nutrition (IDPN). 
 
You asked the Plan to pre-approve IDPN. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that in order to cover IDPN, documentation must be clear and precise to verify that the beneficiary suffers from a permanently impaired gastrointestinal tract and that there is insufficient absorption of nutrients to maintain adequate strength and weight. 
 
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 IDPN. Our reviewer says that the services are not medically necessary. Our physician reviewer found in this care, the provided records state the enrollee has a history of end-stage renal disease (ESRD) on hemodialysis with poor appetite and poor oral intake. Her albumin level is 3.1 with a baseline weight of 59.5 kg and recent 60 kg weight. A request for parenteral nutrition was requested. Although evidence of protein malnourishment was documented, the provided records did not show a clear failed attempt to use enteral nutrition support (tube feeds). Also, the records do not show evidence of her having a significantly abnormal or impaired gastrointestinal tract contributing to the poor oral intake. Without these criteria having been met, the enrollee does not meet the coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IDPN have not been met. Therefore, we decided that the Plan does not have to pre-approve intradialytic parenteral nutrition (IDPN).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) services provided to the enrollee from September 1, 2019 through September 4, 2019.You asked the Plan to waive the copayment for the SNF services. The Plan denied your request. The Plan says that cost sharing is a contractual agreement of the plan and cannot be waived.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 a $160 copayment for each day for days 21 to 62 of SNF care. The enrollee has been asked to pay a $320 copayment for the SNF services. The file indicates the enrollee was in a SNF from August 2, 2019 through August 3, 2019 and August 14, 2019 through September 4, 2019. The file indicates the enrollee was in a SNF for a total of twenty-two (22) days. The SNF services falls within the days 21 to 62 of SNF care 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 copayment for the skilled nursing facility (SNF) services provided to the enrollee from September 1, 2019 through September 4, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve deep brain stimulation (DBS) for the treatment of treatment-refractory obsessive compulsive disorder (OCD).You asked the Plan to pre-approve deep brain stimulation (DBS). You say that DBS for the treatment of treatment-refractory OCD is medically necessary for the enrollee in this case.The Plan denied your request. The Plan says DBS is not medically 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 deep brain stimulation (DBS). Our reviewer says that DBS is not medically necessary. Our physician reviewer found the enrollee has had OCD since 2008. She has had multiple struggles and feels her life is unbearable. The OCD symptoms have affected her relationship with her mother and son. She has been tried on different medications including SSRIs and exposure therapy with no improvement of her symptoms.  Based on review of the literature and documentation provided shows the procedure is inconsistent on a definitive treatment. Based on review the information and documentation, this enrollee has been treated with different therapies which are considered mainstay and have not been successful. It is unfortunate that the procedure that is being asked for is not considered a mainstay treatment for Obsessive-Compulsive Disorder and is considered reasonable or medically necessary due to the inconclusive evidence.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of deep brain stimulation (DBS) have not been met.Therefore, we decided that the Plan does not have to pre-approvedeep brain stimulation (DBS) for the treatmentof treatment-refractory obsessive compulsive disorder (OCD).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve Prolia (denosumab) treatments. 
 
You asked the Plan to pre-approve the Prolia treatments. You say that this treatment is necessary to prevent worsening of bone density. The Plan denied your request. The Plan says that there is not sufficient documentation to support that criteria are met. 
 
The Plan follows Medicare rules. Medicare rules say that Prolia is covered for treatment of osteoporosis when the above criteria are met.  
 
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 Prolia treatments. Our reviewer says that based on the information submitted, the requested use of Prolia is shown to be medically reasonable and necessary. Our physician reviewer found the enrollee is a 65-year-old female with osteoporosis and reported history of osteoporotic fracture. Prolia has been requested. The Plan denied the Prolia due to lack of information to support its use. On 06/09/2020, the prescriber sent additional information and medical records addressing the Plan's coverage criteria. The prescriber sent records indicating a bone density test from 02/28/2019 that showed a hip T score of -2.5 which was a decrease from prior scans. Also the medical records provided reported a history of a hip fracture that occurred from a standing height in 2014. Another tibia/fibula fracture occurred in 2015 stepping out of a van. Laboratory records were provided indicating a normal calcium level of 9.6 mg/dL from 10/2019 and a vitamin D level of 30.1 ng/dL from 02/2019. Records indicate the enrollee is on 1000 mg of calcium daily along with 400 units of vitamin D in supplement form. She has taken Actonel in the past but will be on Prolia as a single agent. The LCD criteria for this treatment have been 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 the Prolia treatments have been met. Therefore, we decided that the Plan has to pre-approve Prolia (denosumab) treatments. If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (CPT 73070) provided to the enrollee on February 3, 2020.You asked the Plan to pay for the services. You say that this should be paid for.The Plan denied your request. The Plan says the provider has been informed that this service was billed in correctly.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 73070 is "Radiologic examination, elbow; 2 views."We find that CPT code 73070 is not supported in the medical record. Specifically, this code is a column II to the column I code -CPT 73080 -already billed on this claim. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plan does not have to pay for radiology services (CPT 73070) provided to the enrollee on February 3, 2020.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to waive the copayment for urgent care visit. We decided that the Plan does not have to waive the copayment for urgent care visit.  
 
You asked the Plan to waive the copayment for urgent care visit. You say that you gave the provider your insurance card a paid the copayment at the visit. The Plan says that the copayment amount you are being charged is correct. 
 
We decided that the Plan has to reduce the copayment for urgent care visit.  
 
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 $35 copayment for an urgent care visit to an urgent care center. The place of service for this visit was an urgent care center, therefore the urgent care center copayment applies to this claim. 
 
The Plan says that you must pay $45 copayment for urgent care visit. Based on the Plan contract, however, you cannot be asked to pay more than $35 copayment for urgent care visit. Therefore, we decided that the Plan has to reduce the copayment for urgent care visit from $45 to $35. We also decided that the Plan does not have to waive the copayment for urgent care visit. 
 
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 $35 copayment for an urgent care visit to an urgent care center. Therefore, we decided that the Plan does not have to waive the copayment for urgent care visit. 
 
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 personal care services (T1019) provided on December 8, 2019 to December 14, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for OON personal care services. You say that these services were authorized. The Plan denied your request. The Plan says there is not a valid authorization for these dates. 
 
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 personal care services (T1019) provided on December 8, 2019 to December 14, 2019 by an out of network (OON) provider
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab services provided on March 17, 2020. 
 
You asked the Plan to waive the copayment for lab services. You say that you had to switch doctors and you feel the new doctor is ordering too many tests and you should not be responsible for 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 $5 copayment for lab services provided by a primary care provider.  
 
You have been asked to pay a $5 copayment for lab services. Lab services fall 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 lab services provided on March 17, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic mammogram provided on January 23, 2020. You asked the Plan to waive the copayment for a diagnostic mammogram. You say that you state that due to your history of breast cancer the doctor is thorough and you feel that the additional testing should be covered as a screening. 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 $100 copayment for diagnostic procedures and tests provided in an outpatient hospital facility. You have been asked to pay the allowed amount of $52.44, which is less than the $100 copayment for a diagnostic mammogram. A diagnostic mammogram 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 a diagnostic mammogram provided on January 23, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued physical therapy (PT) and occupational therapy (OT). 
 
You asked the Plan to pre-approve continued PT and OT. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the enrollee's medical records and confirm that Medicare coverage criteria have been met.    
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued PT and OT have not been met. Specifically, medical records were not provided. Without this documentation, medical necessity is not able to be established. Therefore, we decided that the Plan does not have to pre-approve continued physical therapy (PT) and occupational therapy (OT).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Computed Tomography (CT) of the head and brain (70450) provided September 17, 2019. 
 
You asked the Plan to waive the copayment for the CT scan. You say that you should only be billed an Emergency Room copayment. The Plan denied your request. The Plan says when advanced imaging procedures are performed in the Emergency Room, only the imaging copayment is charged. 
 
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 $225 copayment for advanced imaging.  
 
You have been asked to pay a $225 copayment for the CT scan. The CT scan falls within the advanced imaging 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 Computed Tomography (CT) of the head and brain (70450) provided September 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for office visit services received on January 9, 2020.
You asked the Plan to pay for the services. You say that you have been seeing this doctor since 2017, and you didn't know that you needed to change. The Plan denied your request. The Plan says there is no documentation that you were referred to this non-contracted provider by a contracted 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 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 office visit services received on January 9, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the cemiplimab-rwlc and administration provided on December 19, 2019 or waive the copayment for the inpatient hospital care provided from December 26, 2019 through January 2, 2020.
You asked the Plan to waive the coinsurance for the cemiplimab-rwlc and administration and waive the copayment for the inpatient hospital care. You say that you do not have the money to pay the cost shares. The Plan denied your request. The Plan says that cost shares are a contractual obligation and cannot be waived.
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 each Medicare-covered chemotherapy drug and the administration of that drug and a $320 copayment for each day for days 1 to 5 for Medicare-covered hospital care. You have been asked to pay less than a 20% coinsurance for the cemiplimab-rwlc and administration and a $1,600 copayment for the inpatient hospital care. The cemiplimab-rwlc and administration fall within the Medicare-covered chemotherapy drug and the administration of that drug and the inpatient hospital care falls within the days 1 to 5 for Medicare-covered 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 coinsurance for the cemiplimab-rwlc and administration provided on December 19, 2019 or waive the copayment for the inpatient hospital care provided from December 26, 2019 through January 2, 2020.