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

We decided that the Plan does not have to pre-approve foot orthotics.

You asked the Plan to pre-approve foot orthotics. You say that you would like reconsideration because these inserts are medically necessary.The Plan denied your request. The Plan says this item is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.

Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition.Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the emergency services provided.

You asked the Plan to waive the deductible for the emergency services. You say that your organization was not paid the usual and customary amount for these services.The Plan denied your request. The Plan says this member had not met their deductible prior to these services being rendered. That is why the Plan didn't pay for these services.The member is responsible for paying for their care directly until the deductible is satisfied.

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 $1000 deductible

The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1000 deductible. This cost sharing is a contractual obligation that had not been met at the time the emergency services were received.Therefore, we decided that the Plan does not have to waive the deductible for the emergency services provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner services providedon January 31, 2020.You asked the Plan to pay for the nurse practitioner services.The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization. Medicare rulessay 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 servicesat issue. We found no exception that would requirethe Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for nurse practitioner services providedon January 31, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an MRI of the lumbar spine.
You asked the Plan to pre-approve an MRI of the lumbar spine. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the documentation does not support that the requested services are medically necessary.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. We looked at the file and Medicare rules. Review of the file shows that no medical records were provided to support that the requested MRI scan is medically reasonable or necessary. Based on this information, we decided that Medicare rules for coverage of an MRI of the lumbar spine have not been met. Therefore, we decided that the Plan does not have to pre-approve an MRI of the lumbar spine.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foranesthesia services provided on July 16, 2020 by an out of network (OON) provider.You asked the Plan to pay foranesthesia services. You say that you would like this claim reprocessed and paid.The Plan denied your request. The Plan says prior authorization was not 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 availablewho 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 foranesthesia services provided on July 16, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe inpatient rehabilitation hospital services provided from June 5, 2020, to June 29, 2020.You asked the Plan to waive the copayment forthe inpatient rehabilitation hospital services. You say that you already paid the copayment for the inpatient stay, so this charge is duplicative.The Plan denied your request. The Plan says this patient had two separate admissions, so this copayment was charged correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $380 copayment per dayfor days 1-5 for inpatient hospital care. Records show that the enrollee was admitted to an acute inpatient hospital facility from May 31, 2020, to June 5, 2020.  The records then show that the patient was discharged from the acute inpatient hospital facility and admitted to an inpatient rehabilitation facility.  She was in this rehab facility from June 5, 2020, to June 29, 2020.  Since these were two separate and distinct admissions, two separate copayments applied. The enrollee has been asked to pay a $380 copayment per day for days 1-5 for the inpatient rehabilitation hospital services. 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 forthe inpatient rehabilitation hospital services provided from June 5, 2020, to June 29, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital services you received from January 9, 2020, to January 10, 2020.
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you don't believe you should have to pay this copayment because the doctor messed up your hip surgery. The Plan denied your request. The Plan says you were charged this copayment 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 $390 copayment per day for days 1-5 for inpatient hospital care. You have been asked to pay a $390 copayment per day for the inpatient hospital services. This copayment applies regardless of your satisfaction with the care you received. 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 inpatient hospital services you received from January 9, 2020, to January 10, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe emergency room (ER) services you received on February 16, 2020.You asked the Plan to waive the copayment forthe ER services. You say that you were transferred tothe ER via ambulance, so you believe you don't owe this amount.The Plan denied your request. The Plan says you were charged this amount 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 $90 copayment for emergency care. You have been asked to pay a $90 copayment for the ER services. This copayment applies regardless of the reason for the ER visit. 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 forthe emergency room (ER) services you received on February 16, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveOrencia Clickject.You asked the Plan to pre-approvethe Orencia Clickject. You say that this medication is needed for a continuation of care. The appellant says that this is not a new medication and that the enrollee has been using it since February of 2020.The Plan denied your request. The Plan says the requested drug is not covered under Part B coverage. The Plan says that they do not administer any Part D benefits for the enrollee.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-approveOrencia Clickject.Benefits for the Orencia Clickjectmay be available under Medicare Part D.Contactthe 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 pay for the services provided by an out-of-network provider.

You asked the Plan to pay for the services. You say that the claims should be paid.The Plan denied your request. The Plan says this provider is not under contract with the Plan's service area and were not approved in compliance with the Plan's authorization procedures.

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 services provided by an out-of-network provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forthe sleep studies you had on August 25, 2020, and September 10, 2020.You asked the Plan to waive the copayments forthe sleep studies. You say that you were not aware of any copayments or costs for these services.The Plan denied your request. The Plan says you were charged these copayments correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 copayment for outpatient diagnostic tests with a specialty physician. You have been asked to pay a $30 copayment for the sleep studies. The sleep studies fall within the outpatient diagnostic tests with a specialty physician 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 copayments forthe sleep studies you had on August 25, 2020, and September 10, 2020.
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 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. 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 there are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Therefore, this request for LTACH services will be considered not medically necessary at this time. Transfer may be considered when the enrollee's treatment has completed and they are more appropriate for a lower level of care. 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for assistant surgeon services provided to the enrollee on October 2, 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 Medicare guidelines state that an assistant surgeon may not be paid for this procedure.
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for CPT codes 28285, 28313, and 28270. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Additionally, the final two denied codes were reported with an inappropriate modifier. Based upon this information, we find that Medicare coverage criteria for the services have not been met. Therefore, we decided that the Plan does not have to pay for assistant surgeon services provided to the enrollee on October 2, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay fornursing facility care (99308) provided on June 17, 2020.You asked the Plan to pay fornursing facility care. You say that these services were medically necessary.The Plan denied your request. The Plan says rules for payment have not been met.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay fornursing facility care (99308) provided on June 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic mammogram and an ultrasound provided by a participating provider on July 14, 2020.You asked the Plan to waive the copayment for a diagnostic mammogram and an ultrasound. You say that you do not feel like you owe both of these copayments. The Plandenied your request. The Plan says the correct copayments have 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 $20 copayment for outpatient diagnostic tests/in-network/diagnostic procedures and tests/specialist's office and outpatient diagnostic tests/in-network/diagnostic mammography/specialist's office. You have been asked to pay a $20 copayment for a diagnostic mammogram and a $20 copayment for anultrasound. The total amount you are being asked to pay is $40 ($20 + $20 = $40). A diagnostic mammogram falls within the outpatient diagnostic tests/in-network/diagnostic procedures and tests/specialist's office and an ultrasound falls within the outpatient diagnostic tests/in-network/diagnostic mammography/specialist's office 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 paywhen you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a diagnostic mammogram and an ultrasound provided by a participating provider on July 14, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvePaclitaxel (J9267) with Famotidine (J3490), Ondansetron (J2405), Diphenhydramine HCL (J1200), and Dexamethasone (J1100)You asked the Plan to pre-approvePaclitaxel and supporting drugs. You say that this service is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet clinical criteria for coverage.The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Paclitaxel and supporting drugs. Our reviewer says that this service is not medically necessary. Our physician reviewer found Paclitaxel is not approved in any relevant compendia when used as combination therapy in patients that have already progressed on Keytruda (pembrolizumab).We looked at this physician's review,the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Paclitaxel and supporting drugs have not been met.Therefore, we decided that the Plan does not have to pre-approvePaclitaxel (J9267) with Famotidine (J3490), Ondansetron (J2405), Diphenhydramine HCL (J1200), and Dexamethasone (J1100)
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forlab services provided on August 20, 2020, and August 31, 2020.You asked the Plan to waive the copayment forlab services. You say that you feel the lab services should be considered as part of an annual wellness visit and 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 $25 copayment for lab services.You received lab services on August 20, 2020. Labs are not included in annual wellness visits and are subject to separate cost-sharing charges. Therefore, you are responsible to pay the allowed amount of $20.17, which is less than the $25 copayment.  You received lab services on August 31, 2020. Labs are not included in annual wellness visits and are subject to separate cost-sharing charges. Therefore, you are responsible to pay the allowed amount of $16.59, which is less than the $25 copayment.  The total amount you owe is: $36.76. You have been asked to pay the total copayment amount of $36.76 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 forlab services provided on August 20, 2020, and August 31, 2020
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on February 20, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services were not approved in advance.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has topay 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 forthe medical services provided to the enrollee by an out-of-network provider on February 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a cystourethroscopy (52332) performed on September 24, 2020.
You asked the Plan to waive the copayment for a cystourethroscopy. You say that the provider had to discontinue and reschedule the procedure and you do not feel it is appropriate that you should have to pay two copayments. The Plan denied your request. The Plan says the correct copayment was 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 $275 copayment for outpatient surgery at a freestanding ambulatory surgical center. You have been asked to pay a $275 copayment for a cystourethroscopy. A cystourethroscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 cystourethroscopy (52332) performed on September 24, 2020.