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

We decided that the Plan does not have to waive the copayment for a specialist visit provided on January 27,
2020.
You asked the Plan to waive the copayment for a specialist visit. You say that this was a follow-up visit 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 $20
copayment per visit to a specialist.
You had a specialist visit on January 27, 2020. Follow-up visits are subject to cost-sharing charges. Therefore,
you are responsible to pay the $20 copayment.
You have been asked to pay a $20 copayment for a specialist visit. A specialist visit falls within the
Physician/Practitioner services, including doctor's office visits benefit category. This means that you have been
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have
to waive the copayment for a specialist visit provided on January 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.
You asked the Plan to pre-approve incontinence supplies. You say that the enrollee has not been able to receive her incontinence supplies and wipes. You say that you want to appeal the Plan's denial of the requested items. You stated that the enrollee needs the requested items and cannot go out because of Covid-19. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9328) provided on September 17,2019 through November 5, 2019.
You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration because this service was medically necessary. The Plan denied your request. The Plan says CPT code S9328 is not payable by Medicare.
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 S9328 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code S9328 has a status code of I. This means that CPT code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9328) provided on September 17,2019 through November 5, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (HCPCS G0483) provided to the
enrollee on December 9, 2019.
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 Healthcare Common Procedure Coding System (HCPCS) G0483 (1 Unit) remains not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of HCPCS G0483 is:
Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and
distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms
(any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia,
elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally
recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in
signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g.,
to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes
specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed
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 pay for the services. Our reviewer says that the
services at issue in this case were not coded correctly. Our physician reviewer found the medical records
provided does not have a lab requisition order signed by the ordering physician. The office visit note included,
does not state exactly what tests were to be performed. The lab results included in the medical record only
validates that 21 drug classes were tested, which does not meet definition description of HCPCS code G0483,
therefore this service cannot be verified.
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 services have not been met. Therefore, we decided that the Plan does not
have to pay for drug testing services (HCPCS G0483) provided to the enrollee on December 9, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ER visit provided from January 30, 2020 to February 5, 2020.
You asked the Plan to waive the copayment for an ER visit. You say that you disagree with the hospital admission charges. The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $65 copayment for emergency care. The medical records show that the enrollee had an observation stay following an ER visit on January 30, 2020. Therefore, the enrollee is responsible to pay the $65 copayment. Please note that this is in the enrollee's financial favor. The enrollee has been asked to pay a $65 copayment for an ER visit. An ER visit falls within the emergency 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 an ER visit provided from January 30, 2020 to February 5, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for Hepatitis A vaccine services provided on January 31, 2020.
You asked the Plan to pay for the Hepatitis A vaccine services. You say that the incorrect procedure codes were used for this claim. The Plan denied your request. The Plan says the Hepatitis A vaccine and the administration of the vaccine are not covered under Medicare part B. The Plan says that this vaccination is eligible under Medicare Part D.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Hepatitis A vaccine services. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the Hepatitis A vaccine services. Therefore, we decided that the Plan does not have to pay for Hepatitis A vaccine services provided on January 31, 2020.
Benefits for the Hepatitis A vaccine services 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for DME provided on December 27, 2018.
You asked the Plan to waive the deductible for DME. You say that you 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. Your
contract with the Plan says that there is a $1,000 deductible for out-of-network DME and related supplies.
You received DME on December 27, 2018 with an out-of-network provider. Therefore, you are responsible to
pay your share of the out-of-network charges. The record shows that you had only paid $274.08 toward the
$1,000 deductible prior to receiving the services. Therefore, you are responsible to pay the allowed amount of
$400.
The item or service you asked the Plan to waive the deductible for falls within the benefit category DME and
related supplies. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a
$1,000 deductible for out-of-network DME and related supplies. This cost sharing is a contractual obligation
that had not been met at the time DME was received on December 27, 2019. Therefore, we decided that the
Plan does not have to waive the deductible for DME provided on December 27, 2018.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a hospital outpatient clinic visit provided on January 9, 2020.
You asked the Plan to pay for the hospital outpatient clinic visit. The Plan denied your request. The Plan says
you must receive care from in-network providers with the exception of emergency or urgent care, or if the care
cannot be provided with an in-network provider, which requires prior authorization from the plan.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan 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 a hospital outpatient clinic visit provided on January 9, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the transportation services you received on November 3, 2019.
You asked the Plan to pay for the transportation services. The Plan denied your request. The Plan says the transportation was not medically necessary.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 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 pay for the transportation services. Our reviewer says that the requested ambulance transportation was not medically reasonable and necessary. Our physician reviewer found that there is no evidence that the enrollee had a medical emergency requiring the use of an ambulance. There is no evidence that this was an interfacility transfer for the purpose of receiving services that were not locally available. The ambulance transport was not medically necessary or reasonable. 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 transportation services have not been met. Therefore, we decided that the Plan does not have to pay for the transportation services you received on November 3, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 99190) provided on January 23, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment for these
services is included in the Part A DRG payment to the facility.
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other
than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all
necessary covered services to the beneficiary either directly or under arrangements made with outside
providers. Payment for all fees related to this service would have been included under the facility claim.
Therefore, we decided that the Plan does not have to pay for the services (CPT 99190) provided on January 23,
2019.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Opdivo and ipilimumab.
You asked the Plan to pre-approve these services. You say that you are in constant pain and your life is in jeopardy. The Plan denied your request. The Plan says that the services are not medically necessary.
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. The rules say that Opdivo is covered when specific 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 these services. Our reviewer says that the services are medically necessary. Our physician reviewer found the records show that the enrollee received initial Opdivo for metastatic renal cell carcinoma from 2016 to 2017. The medical literature supports the use of Opdivo plus ipilimumab in patients with no prior exposure to ipilimumab. The addition of ipilimumab to Opdivo may boost response rates after progression on single-agent Opdivo. This was demonstrated in preliminary results on study. The services are therefore reasonable and 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 these services have been met. Therefore, we decided that the Plan has to pre-approve Opdivo and ipilimumab.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve freestyle libre continuous glucose monitor (CGM).
You asked the Plan to pre-approve freestyle libre CGM. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested device is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor. We looked at the file and Medicare rules. Review of the file does not support that the enrollee is treated with frequent (3 or more) daily insulin injections or continuous subcutaneous insulin infusion per insulin pump. Based on this information, we decided that Medicare rules for coverage of freestyle libre CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve freestyle libre continuous glucose monitor (CGM).
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 January 8, 2020.
You asked the Plan to waive the copayment for the urgent care visit. You say that you were informed to go to the emergency room or urgent care. You say that you are hoping for a favorable resolution. 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 $30 copayment for urgently needed services at an out-of-network urgent care. You have been asked to pay a $30 copayment for the urgent care visit. The urgent care visit falls within the "Urgently needed services" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the urgent care visit provided on January 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a standing frame.
You asked the Plan to pre-approve a standing frame. You say that a standing frame would give you a way to do
weight bearing activities. The Plan denied your request. The Plan says a standing frame is not covered by
Medicare or the Plan.
The Plan must follow Medicare rules. Medicare rules say that standing frames are not primarily medical in
nature.
We looked at the file and Medicare rules. Standing frames are statutorily not covered by Medicare. Based on
this information, we decided that Medicare rules for coverage of a standing frame have not been met.
Therefore, we decided that the Plan does not have to pre-approve a standing frame.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit and does not have to waive
the coinsurance for a Medicare Part B drug provided on January 21, 2020.
You asked the Plan to waive the copayment for a specialist visit and to waive the coinsurance for a Medicare
Part B drug. You say that you 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 $10
copayment for specialist visits. Your contract with the Plan also clearly says that you must pay 20%
coinsurance for Medicare Part B prescription drugs.
You received a specialist visit on January 21, 2020. Therefore, you are responsible to pay the $10 copayment.
You received a Medicare Part B drug on January 21, 2020. The allowed amount is $15 and 20% of that is $3.
The total amount you owe is: $13.
You have been asked to pay the total amount of $13 for a specialist visit and a Medicare Part B drug. A
specialist visit falls within the physician/practitioner services, including doctor's office visits benefit category.
A Medicare Part B drug falls within the Medicare Part B prescription drugs benefit category.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that
the Plan does not have to waive the copayment for a specialist visit and does not have to waive the coinsurance
for a Medicare Part B drug provided on January 21, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network surgeon.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the services are available from 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 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
a referral to an out-of-network surgeon.
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 records provided support the need for
LTACH care. The Plan denied your request. The Plan says the enrollee does not meet the requirements for
coverage of LTACH care.
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 reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH) for
COPD and pneumonia. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires
services that are not currently available. There is no advantage in transferring the enrollee to the LTACH. The
enrollee can remain at the current ACH until such a time that no acute services are required. The enrollee can
then be transferred/discharged to a lower level of care for any ongoing long term care needs.
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 pre-approve an implantable neurostimulator, pulse generator,
(L8679).
You asked the Plan to pre-approve an implantable neurostimulator, pulse generator. You say that your
authorization has been denied based upon NCD for electrical nerve stimulators (160.7) which is incorrect NCD
for your device. The Plan denied your request. The Plan says the requested service is not medically necessary
or a standard of care for this enrollee.
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 an implantable neurostimulator, pulse
generator. Our reviewer says that the requested items/services are not considered medically reasonable and
necessary in this case. Our physician reviewer found the enrollee has chronic pain, hip osteoarthritis, and
lumbar degenerative disc disease. Appeal documentation indicates the enrollee is receiving a peripheral nerve
stimulator and not implanted. This is not consistent with the submitted billed device, L8679. The intended
device is a peripheral nerve stimulator placed around the ear.
The enrollee's pain syndrome affects her lower extremities. It is not clear from the submitted documentation or
reviewed compendia indication for a peripheral stimulator behind the ear for this enrollee's pain syndrome.
Medical necessity is not supported.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of an implantable neurostimulator, pulse generator have not been met. Therefore,
we decided that the Plan does not have to pre-approve an implantable neurostimulator, pulse generator,
(L8679).