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

We decided that the Plan does not have to waive the copayment for a colonoscopy provided by an in-network provider on November 8, 2019.
You asked the Plan to waive the copayment for a colonoscopy. You say that you went to have a colonoscopy under the belief that this service was covered in full. The Plan denied your request. The Plan says the correct copayment has been applied.
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 $450 copayment for outpatient surgery. You have been asked to pay $357.90 which is less than your copayment amount of $450 copayment for a colonoscopy. The colonoscopy that was provided was diagnostic in nature due to prior concerns. A colonoscopy falls within the outpatient surgery 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 colonoscopy provided by an in-network provider on November 8, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy services provided by from November 9, 2019 to November 16, 2019.
You asked the Plan to pay for home infusion therapy services. You say that the Centers for Medicare and
Medicaid Services (CMS) website lists this as a valid code. The Plan denied your request. The Plan says the
denial of payment for these services is correct, because this procedure code is not valid for Medicare purposes
and is not payable.
The Plan must follow Medicare rules. Medicare rules say that procedure code S9328 is not valid for Medicare
purposes and is not payable.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of home infusion therapy services have not been met. Therefore, we decided that the Plan does not
have to pay for home infusion therapy services provided from
November 9, 2019 to November 16, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9328) provided on September 22, 2019 through September 29, 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 indicator of I and 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 indicator 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 22, 2019 through September 29, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pontic for tooth #3 and retainer crowns for tooth #'s 2 & 4. You asked the Plan to pre-approve the pontic and retainer crowns. The Plan denied your request. The Plan says the services are not medically necessary. Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the pontic and
retainer crowns when the services are medically necessary and reasonable. 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 pontic and retainer crowns. Our reviewer says that the service is not medically necessary. Our physician reviewer found the abutment teeth appear to have adequate bone support if a bridge was to be prepared. Our reviewer found that there has been no showing that, although a three unit bridge is a reasonable treatment plan, that a removable partial denture could
not be utilized. Our physician reviewer found that there would be adequate anchorage in the upper arch for a removable appliance. Our reviewer also found that the criteria requires that there be a showing of why a removable appliance could not be used before considering fixed bridgework, no documentation showing this was provided, and there is no medical necessity for the requested procedures. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the pontic and retainer crowns have not been met. Therefore, we decided that the Plan does not have to pre-approve a pontic for tooth #3 and retainer crowns for tooth #'s 2 & 4.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Celecoxib 200mg capsule medication.
You asked the Plan to pre-approve this medication. You say that the patient has Osteoarthritis and has been
stable on this medication since 2016. The Plan denied your request. The Plan says this medication is not a
covered benefit under the member's contractual policy.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drug requested here is not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve the Celecoxib 200mg
capsule medication.
Benefits for this medication 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 95999 provided on August 2, 2019. You asked the Plan to pay for CPT code 95999. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says CPT code 95999 is 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 code 95999 is unlisted neurological or neuromuscular diagnostic procedure. We find that CPT code 95999 is not supported in the medical record. Specifically, the record shows that train of four testing was performed and this is not the appropriate code for this service. Per Medicare guidelines, it is inappropriate to bill unlisted neurological or neuromuscular diagnostic CPT codes for train of four monitoring. There is no separate code for train of four monitoring. Based on this information, we decided that Medicare rules for coverage of CPT code 95999 have not been met. Therefore, we decided that the Plan does not have to pay for CPT code 95999 provided on August 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 16, 2019 to the enrollee by an out of network (OON) 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 an out-of-network 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 October 16, 2019 to the enrollee by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on November 26, 2019.
You asked the Plan to waive the copayment for the ambulance transport. You say that you should not have to pay the copay. The Plan denied your request. The Plan says that the claim processed 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 $180 copayment for per date of service for ground transportation regardless of the number of trips. You have been asked to pay a $180 copayment for the ambulance transport. The ambulance transport falls within the per date of service for ground transportation regardless of the number of trips 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 ambulance transport provided on November 26, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia subcutaneous solution prefilled syringe 60
mg/ml.
You asked the Plan to pre-approve Prolia. You say that you have tried Ibandronate and Risedronate. You say
that you were not able to tolerate either of the Bisphosphonates. You say that you were prescribed Raloxifene
for years but your physician did not feel it was of any value so she had you stop taking it. You also say that you
had dental implants several years prior to being prescribed Bisphosphonates which is a contraindication to
taking those medications because of the risk of osteonecrosis of the jaw. The Plan denied your request. The
Plan says you must try an oral Bisphosphonate drug (e.g., Alendronate, Ibandronate, Risedronate) and
Zoledronic Acid (generic Reclast) before Prolia can be approved. The Plan says you have tried Ibandronate, but
you have not tried Zoledronic Acid. The Plan also says that the criteria has not been met and your provider has
not demonstrated why it is medically necessary to make an exception for you.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.
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 Prolia. Our reviewer says that the drug
is not medically necessary. Our physician reviewer found the provided documentation indicates that you were
treated with an oral Ibandronate in 2016. The reviewer found that the records do not support that you have
trialed Zoledronic Acid. The provided documentation shows that you have a history of dental implants. The
reviewer found that there is no documented neoplasm, concurrent chemotherapy, or dental infections. The Plan
requires a trial of Zoledronic Acid to meet step therapy requirements. The reviewer found that 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 Prolia have not been met. Therefore, we decided that the Plan does not have to
pre-approve Prolia subcutaneous solution prefilled syringe 60 mg/ml.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the sterile gloves rendered n December 20, 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 are not covered.
The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of X are statutorily excluded. We looked at the file and Medicare rules. The provider submitted a claim for procedure code A4930 (sterile gloves, per pair). This code has a status indicator of X and is statutorily excluded from Medicare payment. Therefore, we decided that the Plan does not have to pay for the sterile gloves rendered on December 20, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode array for the enrollee.
You asked the Plan to pre-approve the surgery. You say that this is medically necessary to help the enrollee with chronic pain. The Plan denied your request. The Plan says no surgical or psychological therapies have been attempted.
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 surgery. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found according to the applicable NCD, a spinal cord stimulator is only covered for use in chronic intractable pain when "other treatment modalities (pharmacological, surgical, physical, or psychological therapies) have been tried and did not prove satisfactory, or are judged to be unsuitable or contraindicated for the given patient". In this case the records provided for review did not demonstrate that all other treatment modalities had been exhausted. The patient had not undergone interventional pain management procedures (e.g. ESI) or surgery. Nor had any imaging studies been completed to date that would show that these other potential treatment modalities are otherwise contraindicated. Consequently the requirements of the NCD have not been met. Therefore the requested procedure would not meet Medicare criteria for coverage. 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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode array for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the ferric carboxymaltose injections provided on October 14, 2019 and October 22, 2019.You asked the Plan to waive the coinsurance for the injections.You say that you were told there would be no cost.The Plan denied your request. The Plan says that there is a 15% coinsurance for Medicare Part B prescription drugs.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 15% coinsurance for Medicare Part B prescription drugs. You have been asked to pay a 15% coinsurance for the injections. The injections fall 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 coinsurance for the ferric carboxymaltose injections provided on October 14, 2019 and October 22, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on October 24, 2019 by an out of network provider
You asked the Plan to pay for the ambulance services. You say that the services were medically necessary. The Plan denied your request. The Plan says you did not request 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 did not pre-approve the service 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 ambulance services provided on October 24, 2019 by an out of network provider
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vyzulta.
You asked the Plan to pre-approve the Vyzulta. You say that you recently started the enrollee on Vyzulta, which has lowered his intraocular pressure (IOP) in both eyes to a safe range. You also say that you would like Vyzulta approved to keep the enrollee's IOP down in the safest range that it has been in years. The Plan denied your request. The Plan says the enrollee has a medical only policy with the Plan, not a Prescription Drug Plan. The Plan also says that drug coverage for the enrollee is limited to Medicare Part B covered drugs.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Vyzulta.
Benefits for Vyzulta 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the manual manipulation of the spine (98941) or pay for extraspinal manipulation (98943), a therapeutic procedure (97110) and whirlpool therapy (97022) provided on September 30, 2019 through October 16, 2019.You asked the Plan to waive the deductible for the manual manipulation of the spine (98941) and pay for the other chiropractic services. You say that you would like the deductible waived and only be held responsible for the copayment amount listed in your contract. The Plan denied your request. The Plan says you are responsible for this amount because it was applied to your plan's deductible.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 deductible of $150 before the Plan will begin to pay their share of the costs for covered services.You have been asked to pay a deductible of $56.58 for the chiropractic services. 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. Additionally, the rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.Extraspinal manipulation (98943), therapeutic procedures (97110) and whirlpool therapy (97022) are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to waive the deductible for the manual manipulation of the spine (98941) or pay for extraspinal manipulation (98943), a therapeutic procedure (97110) and whirlpool therapy (97022) provided on September 30, 2019 through October 16,2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital discharge day management services provided to the enrollee on July 7, 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 the documentation submitted does not include a hospital discharge day management note with a recorded duration of time of 31 minutes or more for the billed date of service of 07/07/2019; therefore, the billed service cannot be verified.
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 99239 is "Hospital discharge day management; more than 30 minutes." 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 supported by the medical records. Our physician reviewer found while a copy of the enrollee's discharge instructions has been submitted for review, no copy of the provider's discharge summary has been submitted for review. Therefore, there is no evidence to support the provision, or billing, of any discharge services, including CPT 99239, on the date of service in question. 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 hospital discharge day management services provided to the enrollee on July 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe special pump services rendered to the enrollee on October 1, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of X are statutorily excluded. The provider submitted a claim for procedure code 99190 (special pump services). This code has a status indicator of X and no separate Medicare payment. Payment is included in the payment to the facility.Therefore, we decided that the Plan does not have to pay forthe special pump services rendered to the enrollee on October 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist services rendered to you on November 5, 2019.
You asked the Plan to waive the copayment for these services. You say that you disagree with the charges. The Plan denied your request. The Plan says the copayment 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 $50 copayment for in-network Medicare-covered specialist services.
Review of the file shows that you received specialist services on November 5, 2019. You have been asked to pay a $50 copayment for these services. These services fall within the in-network Medicare-covered specialist 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 specialist services rendered to you on November 5, 2019.