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

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on May 2, 2019.
You asked the Plan to waive the copayment for the ambulance transport. 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 $250 copayment per one-way ambulance trip. You have been asked to pay a $250 copayment for the ambulance transport. The ambulance transport falls within the one-way ambulance trip 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 May 2, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on November 5, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order/lab requisition or medical records stating exactly what tests are to be performed.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. 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 the drug testing services provided on November 5, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) and
topical application of fluoride varnish (D1206) provided on December 16, 2019.
You asked the Plan to pay for the dental services. You say that the services that you received were preventive
in nature. You say that they should be covered. The Plan denied your request. The Plan says the comprehensive
periodontal evaluation and topical application of fluoride varnish are not listed as covered services. The Plan
also says any services not listed are not covered.
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.
Though the Plan offers a dental benefit in excess of Medicare coverage, the dental services are not among those
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive
periodontal evaluation (D0180) and topical application of fluoride varnish (D1206) provided on December 16,
2019.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a laparoscopic sleeve gastrectomy (43775).
You asked the Plan to pre-approve this service. You say that a laparoscopic sleeve gastrectomy is medically necessary for the enrollee. The Plan denied your request. The Plan says that the enrollee does not meet criteria for coverage of a laparoscopic sleeve gastrectomy.
The Plan follows Medicare rules. The rules say that as of June 27, 2012, stand-alone LSG procedures are no longer nationally non-covered and that individual consideration can be given by the MACs regarding coverage as long as the above listed criteria are met. It should be noted that the absence of a formal LCD does not imply non-coverage of the procedure. 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 this service. Our reviewer says that the enrollee meets criteria for coverage of the requested procedure. Our physician reviewer found that the enrollee is 5 feet 7 inches tall and weighs 389 pounds, giving a body mass index of 60.93 kg/m2. The enrollee has several weight related co-morbid conditions including: Gastroesophageal reflux disease (GERD), Coronary artery disease (CAD), hypertension (HTN) and decreased mobility. Additionally, the enrollee has limited mobility and has failed dietary efforts in the past. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have been met. Therefore, we decided that the Plan has to pre-approve a laparoscopic sleeve gastrectomy (43775).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a drug test provided on November 20, 2019.
You asked the Plan to pay for the drug test. The Plan denied your request. The Plan says the Plan requires
utilization of network providers when possible and available, and requires authorization for certain services. No
medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been
documented.
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
drug test. 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 drug test provided on November 20, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable


 We decided that the Plan does not have to pre-approve admission to inpatient psych April 14, 2020 and forward. 
 
You asked the Plan to pre-approve admission to inpatient psych. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.  
 
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 admission to inpatient psych. Our reviewer says that the documentation does not support that the requested inpatient psych services are medically reasonable or necessary. Our physician reviewer found the documentation do not support that the enrollee would improve in a reasonable period of time beyond the dates in question as he was not showing any dangerousness to self or others without aggressive behaviors or paranoid thinking. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as the enrollee did not have any suicidal or homicidal thoughts, hallucinations or abnormal behaviors. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve the enrollee's condition or for the purpose of diagnosis. Based upon review the records provided, the enrollee does not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of April 14, 2020 forward and could have been treated in a lesser restrictive setting as the enrollee was not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions and was not showing any behaviors or aggression being cooperative and compliant while not showing any acute threats to safety. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of admission to inpatient psych have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to inpatient psych April 14, 2020 and forward.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to provide a Freestyle Libre continuous glucose monitor (CGM). 
 
You asked the Plan to provide the CGM. You say that the CGM is medically necessary. The Plan denied your request. The Plan says that coverage criteria has not been met. 
 
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 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 provide the CGM. Our reviewer says that the CGM is medically necessary. Our physician reviewer found the enrollee checks his blood sugar multiple times a day and the record shows the CGM would be used to modify insulin dosage. 
 
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 CGM have been met. Therefore, we decided that the Plan has to provide a Freestyle Libre continuous glucose monitor (CGM).  
 
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 waive the copayment for a clinic visit provided on January 6, 2020.
You asked the Plan to waive the copayment for the clinic visit. You say that you did not go into a treatment
room. You say you saw a specialist for a visit and nothing was done other than a conversation. 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 $325
copayment for Medicare-covered outpatient hospital services. For this date of service, you have been asked to
pay the allowed amount of the claim because this amount is less than the $325 copayment for the clinic visit.
You have been asked to pay a $87.04 copayment for the clinic visit. The clinic visit falls within the "Outpatient
hospital services" benefit category. The record shows you were billed separately by the hospital for the clinic
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 for the clinic visit provided on January 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient hospital services rendered on
October 3, 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 $325
copayment per visit for outpatient hospital facility services.
Review of the file shows that you received outpatient hospital services on October 3, 2019. Per the contract
with the Plan, there is a $325 copayment per visit for outpatient hospital facility services. This cost sharing is a
contractual obligation you agreed to pay when you enrolled in the Plan. However, the Medicare allowed
amount for these services was $87.04. Given that the allowed amount was less than the $325 copayment, you
have been asked to pay $87.04 for these services.
Therefore, we decided that the Plan does not have to waive the copayment for the outpatient hospital services
rendered on October 3, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Computed Tomography (CT) of the
Abdomen and Pelvis (74176) provided February 12, 2020.
You asked the Plan to waive the copayment for the CT scan. You say that the copayment should be waived.
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 $270
copayment for Advanced Imaging.
You have been asked to pay a $270 copayment for the CT scan. The CT scan falls within the Advanced
Imaging benefit category. This means that you have been asked to pay the correct amount based on your
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the
Plan. Therefore, we decided that the Plan does not have to waive the copayment for Computed Tomography
(CT) of the Abdomen and Pelvis (74176) provided February 12, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the pharmacogenetic testing provided on January 16, 2020.
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the documentation did not include a physician order or medical records stating exactly what tests or panels are to be performed.
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 is not supported in the medical record. The pharmacogenetic testing was ordered to make decisions about the enrollee's medications. Medications should be provided based on the presence of a diagnosis and should be adjusted based on a response to the medication. In this case, there is insufficient medical records to support that the provided pharmacogenetic testing was medically necessary or reasonable. Therefore, we decided that the Plan does not have to pay for the pharmacogenetic testing provided on January 16, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on September 26, 2019.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 laboratory services. 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 laboratory services provided on September 26, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan of the abdomen and the
CT scan of the thorax provided.
You asked the Plan to pay for the CT scans. The Plan denied your request. The Plan says the enrollee's claim
would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the
date of election until the last day of the month in which hospice is revoked. The Plan also says it is the
provider's responsibility to verify the member's coverage before rendering services and to know proper billing
procedures for a Medicare Advantage member on hospice.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Original Medicare is responsible for payment for services until the first day of the month after the
hospice election has been revoked or terminated.
The enrollee ended Medicare Hospice benefits. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan of the abdomen and the CT scan of the thorax provided.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pay for a tetanus, diphtheria toxoids, and acellular pertussis vaccine (TDAP) provided.
You asked the Plan to pay for the TDAP vaccine. You say that you injured your right finger and the in-network provider advised you to get the vaccine in dispute. The Plan denied your request. The Plan says that payment for the TDAP vaccine was appropriately denied, per Medicare rules and the enrollee's contract language.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. The TDAP vaccine is normally not covered, but could be under some conditions. You were referred for the TDAP vaccine by a contract provider. The file does not show that the Plan provided notice that the TDAP vaccine would not be covered. Under Medicare rules, this means the TDAP vaccine is considered approved by the Plan. Therefore, we decided that the Plan has to pay for a tetanus, diphtheria toxoids, and acellular pertussis vaccine (TDAP) provided.
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient services (99292) provided July 22, 2019.
You asked the Plan to pay for the inpatient visit. You say that the services were medically necessary and
supported by the records. The Plan denied your request. The Plan says the claim was submitted incorrectly.
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 99292 is not supported in the medical record. Specifically, code 99292 is an add-on
code and should have been billed on the same claim as the primary code (99291). The services were submitted
on separate claims. Based on this information, we decided that Medicare rules for coverage of the inpatient
visit have not been met. Therefore, we decided that the Plan does not have to pay for inpatient services (99292)
provided July 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the ustekinumab injection
You asked the Plan to waive the coinsurance for the ustekinumab injection. You say that you were not
informed what the cost would be. You say that you assumed insurance would cover it. The Plan denied your
request. The Plan says the coinsurance 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 20%
coinsurance for in-network, Medicare covered Part B drugs and other Medicare covered items.
You have been asked to pay a total of $2,518.72 for the ustekinumab injections.
Date of Service Service Allowed Amount Coinsurance Member Liability
November 6, 2019 Ustekinumab Injection $6,296.81 20% $1,259.36
December 4, 2019 Ustekinumab Injection $6,296.81 20% $1,259.36
TOTAL: $2,518.72
The ustekinumab 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 ustekinumab injection
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a cytoscopy (52000) provided on November 14, 2019.You asked the Plan to waive the copayment for the cytoscopy. You say that you would like reconsideration because you should not have to pay more than the Plan for this service.The Plan denied your request. The Plan says you are liable for the $400 copayment that was applied to this service.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 $400copayment for outpatient surgery performed in an outpatient hospital setting.You have been asked to pay a $400 copayment for the cytoscopy. The cytoscopy falls within the outpatient surgery performed in an outpatient hospital setting 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 fora cytoscopy (52000) provided on November 14, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says this item is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient lab work provided by an out of network (OON) provider.
You asked the Plan to pay for outpatient lab work. You say that these services were medical necessity. 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 outpatient lab work provided on by an out of network (OON) provider.