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

We decided that the Plan does not have to pay for the medical services provided on December 26, 2019 by an out of network (OON) provider.
You asked the Plan to pay for practitioner visit. You say that the facility requested this provider, therefore medical necessity was pre-established. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and 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 December 26, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (HCPCS S9328) provided to the enrollee from December 19, 2019 to December 26, 2019.
You asked the Plan to pay for the therapy. You say that this should be paid for. The Plan denied your request. The Plan says this is an invalid procedure code for this service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate procedure code. In this case, the CPT Code Manual definition of HCPCS code S9328 is "Home infusion therapy, implanted pump pain management infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem." We find that HCPCS code S9328 is not supported in the medical record. Specifically, this code has a status indicator of I according to the Medicare Physician's Fee Schedule. This indicates that the code is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the therapy have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (HCPCS S9328) provided to the enrollee from December 19, 2019 to December 26, 2019.
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 on October 31, 2019.
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 on October 31, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the physical therapy visit provided on December 16, 2019.
You asked the Plan to waive the copayment for the physical therapy visit. You say that you were under the impression your insurance would cover the therapy and you were never told you would have to pay. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for each in-network Medicare covered therapy visit. You have been asked to pay a $40 copayment for the physical therapy visit. The physical therapy visit falls within the "Outpatient rehabilitation 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 physical therapy visit provided by on December 16, 2019.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a K3 prosthesis and accessories.
You asked the Plan to pre-approve a K3 prosthesis and accessories. You say that the requested K3 prosthesis and accessories are medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested K3 prosthesis and accessories.
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 a K3 prosthesis and accessories. Our reviewer says that the enrollee does not meet criteria for the requested K3 prosthesis and accessories. Our physician reviewer found the enrollee has had a left transtibial amputation for several years due to peripheral artery disease (PAD). The documentation does not support that a K3 prosthesis is medically necessary. The documentation does not reveal that the enrollee has vocational, therapeutic, or exercise activity that demands prosthetic utilization beyond simple locomotion. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a K3 prosthesis and accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a K3 prosthesis and accessories.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the myocardial perfusion imaging (MPI) and stress test rendered on October 28, 2019.
You asked the Plan to waive the cost sharing for these services. You say that the cost sharing is a financial hardship. The Plan denied your request. The Plan says the cost sharing 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). Your contract with the Plan clearly says that you must pay a $200 copayment for nuclear stress tests and a 20% coinsurance for non-nuclear stress tests (treadmill, drug, etc).
Review of the file shows that you received MPI on October 28, 2019. This is a nuclear stress test. You have been asked to pay a $200 copayment for these services. These services fall within the nuclear stress tests 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.
The file shows that you received a non-nuclear stress test on October 28, 2019. You have been asked to pay a 20% coinsurance for these services, for a total of $12.86. These services fall within the non-nuclear stress tests 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 cost sharing for the myocardial perfusion imaging (MPI) and stress test rendered on October 28, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9328) provided on October 3, 2019 through October 10, 2019.
You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration because per CMS, CPT code S9328 is valid. The Plan denied your request. The Plan says CPT code S9328 has a status code of I which is not valid for Medicare purposes.
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 October 3, 2019 through October 10, 2019.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to waive the copayment for the EEG provided on September 27, 2019 and September 28, 2019.
You asked the Plan to waive the copayment for the EEG. You say that the procedure was necessary due to recurring seizures. The Plan denied your request. The Plan says that the claim reprocessed to only apply one $300 copayment.
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 enrollees must pay a $0 copayment for Medicare-covered routine lab and diagnostic tests and procedures. The Plan says you must pay a $300 copayment for the EEG. Based on the Plan contract, however, you cannot be asked to pay more than a $0 copayment for the EEG. The Evidence of Coverage does not say that diagnostic tests provided at an outpatient hospital are excluded from the $0 copayment. Therefore, we decided that the Plan has to waive the copayment for the EEG provided on September 27, 2019 and September 28, 2019.
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: Partially Favorable

We decided that the Plan has to reduce the copayments for the OMT services on August 6, 2019 and September 3, 2019. We decided that the Plan does not have to waive the copayment for the office visit on August 20, 2019.
You asked the Plan to waive the copayments for OMT services and the office visit. You say that there was no transparency on what services were being provided and what the correlating charges would be. The Plan says that you have been charged the correct cost sharing amount.
We decided that the Plan has to reduce the copayments for the OMT services on August 6, 2019 and September 3, 2019.
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles, and coinsurance). The records show that the OMT services (98926/98925) are considered physician services.
The Plan says that you must pay a $30 copayment for the OMT services on August 6, 2019 and September 3, 2019. Based on the plan contract, however, you cannot be asked to pay more than a $5 copayment for the OMT services. Therefore, we decided that the Plan has to reduce the copayment for service from a $30 copayment on each date of service to a $5 copayment on each date of service.
We also decided that the Plan does not have to waive the copayment for the office visit on August 20, 2019.
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 the office visit. Therefore, we decided that the Plan does not have to waive the copayment for the office visit on August 20, 2019.
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 medical services provided on December 30, 2019 by a non-participating provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by a non-participating provider without prior authorization.
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 December 30, 2019 by a non-participating provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray of the spine (72080) provided on December 11, 2019.
You asked the Plan to pay for the x-ray. You say that you would like reconsideration because you were told the x-rays would be covered. The Plan denied your request. The Plan says this service is excluded from coverage when performed by a chiropractor and is not covered per the EOC.
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 x-ray of the spine (72080) provided on December 11, 2019.
Your complaint about receiving incorrect information from the Plan is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on November 5, 2019 by an out of network (OON) provider.
You asked the Plan to pay for lab work. You say that you do not see the patient. You say that these services were referred to you. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the referring provider is also out-of-network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 lab work provided on November 5, 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 provided on November 8, 2019
You asked the Plan to pay for the office visit. You say that you would like reconsideration because you have been reimbursed for claims from this provider in the past. The Plan denied your request. The Plan says this provider has opted out of Medicare, therefore the claim has denied correctly.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by a provider who has opted out of Medicare. Therefore, we decided that the Plan does not have to pay for an office visit provided on November 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis with suspension sleeve rendered on October 30, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that a knee orthosis 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 pay for these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the documentation in the case file does not support that the requested knee orthoses with sleeves were medically reasonable and necessary for the enrollee in this case. There is no documentation of recent injury to, or recent surgical procedure on, either of the enrollee's knees, and there is no objective documentation of joint laxity. The item coded L2397 (sleeve) is not separately payable when the base item is not covered. 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 pay for the knee orthosis with suspension sleeve rendered on October 30, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve the SNF care. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says that you do not meet criteria for coverage of inpatient skilled nursing facility care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 SNF care. Our reviewer says that inpatient skilled nursing facility care is not medically necessary. Our physician reviewer found that you do not require skilled nursing or skilled therapy services on a daily basis. Additionally, you do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve an inpatient skilled nursing facility (SNF) admission.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Spinraza.
You asked the Plan to pre-approve Spinraza. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that Spinraza is only covered for certain indications.
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 Spinraza. Our reviewer says that the documentation does not support that the Spinraza injections are medically reasonable or necessary. Our physician reviewer found the enrollee has a diagnosis of spinal muscular atrophy. The genetic testing from October 23, 2017 yielded indeterminate results. There is no documentation of improvement in motor function, stability in motor function or a slower rate of decline in motor function due to Spinraza treatment based on a standard measurement scale in SMA associated symptoms. Therefore, the enrollee does not meet criteria for Spinraza. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Spinraza have not been met. Therefore, we decided that the Plan does not have to pre-approve Spinraza.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Romiplostim for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is the only intervention that has provided the enrollee with a sustained response in platelet count. The Plan denied your request. The Plan says this is not FDA-approved for treatment of chronic thrombocytopenia (or low platelet count) due to an inherited disorder (Epstein syndrome).
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 the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the enrollee has thrombocytopenia secondary to Epstein syndrome, an inherited condition. She does not have ITP. Romniplostim is not FDA approved for use for inherited thrombocytopenia and is not supported in the
Medicare compendia for off label use for this condition. The documentation does not support that the Romiplostim is medically reasonable and necessary for the patient. The documentation does not support that the Romiplostim is safe and effective for the enrollee. 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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Romiplostim for the enrollee.