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

We decided that the Plan does not have to waive the copayment for a spinal canal injection provided on February 6, 2020.
You asked the Plan to waive the copayment for a spinal canal injection. You say that the vial broke and you do not think that you received a shot. 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 $35 copayment per specialist visit. You have been asked to pay the allowed amount of $12.13, which is less than the $35 copayment for a spinal canal injection. A spinal canal injection falls within the physician/practitioner services, including doctor's office visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a spinal canal injection provided on February 6, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on February 23, 2020.
You asked the Plan to waive the copayment for ambulance services. You say that you disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly, and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $180 copayment for ambulance services. You have been asked to pay a $180 copayment for ambulance services. Ambulance services fall within the ambulance 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 ambulance services provided on February 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided by an out-of-network provider 
on February 3, 2020. 
 
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 by an out-of-network provider on February 3, 
2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on September 24, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code cannot 
be verified. 
 
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 September 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on 
December 31, 2019. 
 
You asked the Plan to pay for this claim. You say that this claim should be paid. The Plan denied your request. 
The Plan says the enrollee did not have prior authorization for out of network care. 
 
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 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 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 out of network physician services provided to the enrollee on December 31, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided from January 1, 2020 through 
January 7, 2020. 
 
You asked the Plan to pay for physical therapy. You say that the interventions require the judgment, knowledge 
and unique skills of a qualified therapist. You say that all denied visits should be covered. The Plan denied your 
request. The Plan says the therapy does not meet criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 physical therapy. Our reviewer says that 
skilled services were not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that the nursing staff was provided with instructions on transfers, 
ambulation, bed mobility and range of motion. Our reviewer says that the unique skills of a professional 
therapist were not required to safely and effectively provide treatment. 
    
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physical therapy have not been met. Therefore, we decided that the Plan does 
not have to pay for physical therapy provided from January 1, 2020 through January 7, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient surgery and self-administered drugs provided from 
January 15, 2020 to January 19, 2020. 
 
You asked the Plan to pay for outpatient surgery and self-administered drugs. You say that you believed this 
surgery would be outpatient, but your condition required you to stay in the hospital multiple nights. The Plan 
denied your request. The Plan says the coinsurance amount you are being charged is correct, and the denial of 
payment for self-administered drugs is correct because these drugs are covered by your Medicare Part D 
benefits. 
 
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 10% 
coinsurance for in-network outpatient surgery at an outpatient hospital, up to a maximum out-of-pocket amount 
of $2,100 for 2020. The rules also say that Medicare Part B generally does not pay for self-administered drugs. 
At the time this claim was processed, $418.04 of the $2,100 maximum out-of-pocket amount had been met. 
The allowed amount of the surgery is $30,673.03, resulting in a coinsurance obligation of $1,681.96 because 
this amount meets the $2,100 maximum out-of-pocket amount for 2020. Additionally, the denied amount for 
self-administered drugs is $70.62. These drugs are not covered by Medicare Part B and payment for them 
should be requested under your Medicare Part D prescription drug benefits. 
 
You have been asked to pay 10% coinsurance for outpatient surgery. Outpatient surgery 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. The self-administered drugs that were denied on this claim are not among those covered by Medicare Part 
B. Therefore, we decided that the Plan does not have to pay for outpatient surgery and self-administered drugs 
provided from January 15, 2020 to January 19, 2020.  
 
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers your Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prochlorperazine.
You asked the Plan to pre-approve Prochlorperazine. 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 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 Prochlorperazine. Our reviewer says that the documentation does not support that the requested drug is medically reasonable or necessary. Our physician reviewer found the enrollee has a diagnosis of rectal cancer who is undergoing chemotherapy treatment with a side effect of nausea and vomiting. The documentation does not support whether the medication is being initiated within 2 hours of the administration of chemotherapy and continued for a period not to exceed 48 hours from that time or whether the medication is used as a full therapeutic replacement for intravenous (IV) anti-emetic therapy that would have been administered at the time of the cancer chemotherapy treatment. Therefore, the documentation does not support that this drug 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 Prochlorperazine have not been met. Therefore, we decided that the Plan does not have to pre-approve Prochlorperazine.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visit provided on 
March 27, 2020. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that this was a consultation 
service and do not know why it is being denied. 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 $50 
copayment for Medicare-covered in-network physician specialist services.  
 
You have been asked to pay a $50 copayment for the specialist office visit. The specialist office visit falls 
within "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows 
that the specialist office visit was not denied. 
 
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 office visit provided on March 27, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a small intestinal endoscopy provided on 
February 24, 2020. 
 
You asked the Plan to waive the deductible for a small intestinal endoscopy. You say that you disagree with the 
charges because you feel that an endoscopy should be considered preventative. The Plan denied your request. 
The Plan says the claims were processed correctly, and you are being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $750 deductible for outpatient surgery, including services provided at 
hospital outpatient facilities and ambulatory surgical centers.  
 
You received a small intestinal endoscopy on February 24, 2020. A small intestinal endoscopy is considered an 
outpatient surgical procedure. The record shows that you had paid $255.98 toward the $750 deductible prior to 
receiving the services. Therefore, you are responsible to pay the remaining deductible amount of $494.02.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. The Plan 
has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible for outpatient 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. This cost 
sharing is a contractual obligation that had not been met at the time a small intestinal endoscopy was received 
on February 24, 2020. Therefore, we decided that the Plan does not have to waive the deductible for a small 
intestinal endoscopy provided on February 24, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse the copayment for an EGD provided on February 27, 
2020. 
 
You asked the Plan to reimburse the copayment for an EGD. You say that the EGD was not routine because 
you had a surgical procedure to remove a foreign object. 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 $390 
copayment for each outpatient hospital visit. 
 
You received an EGD at an outpatient hospital facility on February 27, 2020. An EGD is considered an 
outpatient surgical procedure. Therefore, you are responsible to pay the $390 copayment.  
 
You have been asked to pay a $390 copayment for an EGD. An EGD falls within the outpatient surgery, 
including services provided at hospital 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 reimburse the copayment for an EGD provided on February 27, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab work provided on April 7, 2020 by an out of network 
(OON) provider. 
 
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and approved for 
payment. The Plan denied your request. The Plan says prior 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 lab work provided on April 7, 2020 by an out of 
network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient hospital services provided on March 3, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for outpatient hospital services. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says prior 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 outpatient hospital services provided on March 3, 
2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services (HCPCS G0482) provided to the 
enrollee on September 25, 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 did not include a 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 providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of HCPCS code G0482 is Drug test(s), definitive, utilizing (1) 
drug identification methods able to identify individual drugs and distinguish between structural isomers (but 
not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any 
type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods 
(e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all 
samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or 
drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations 
and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-
21 drug class(es), including metabolite(s) if performed. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found an order 
form from January 1, 2019 was submitted, but it is missing the enrollee's name. No other documentation from 
9/25/2019 was provided. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for drug testing services (HCPCS G0482) provided to the enrollee on September 25, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hysterectomy and bilateral oophorectomy.
You asked the Plan to pre-approve the planned surgery. You say that it is felt that hysterectomy would benefit this patient by eliminating menstruation-related issues. The Plan denied your request. The Plan says there is not sufficient documentation on the history of pain and heavy bleeding nor any clear diagnostic testing or noted treatments which have failed.
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 planned surgery. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is a transgender male with complaints of dysmenorrhea and heavy periods. The patient has decreased testosterone supplementation to avoid deepening of voice. A vaginal ultrasound reveals no uterine pathology. There is no evidence of anemia. No additional work-up has been performed to identify source of pelvic pain. At this time, the requested surgical intervention is not medically necessary as a full work-up has not been completed. 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 planned surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve hysterectomy and bilateral oophorectomy.
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 January 7, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network deficiency for these services.
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 January 7, 2020.