Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pay for the Eylea injection provided on January 28, 2020.
You asked the Plan to pay for the Eylea injection. You say that the enrollee was provided this injection as it
was medically necessary. The Plan denied your request. The Plan says that this injection was not prior
authorized according to plan policy and did not meet criteria.
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 pay for the Eylea injection. Our reviewer says that
the eye injection provided is considered medically reasonable and necessary for this enrollee. Our physician
reviewer found treatment of the patient's macular degeneration with intravitreal injection of aflibercept (Eylea)
was medically necessary based on information in the history and physical. The patient had a diagnosis that
indicated treatment with the drug and the drug was used appropriately. Aflibercept is well established as
standard of care treatment for the patient's disease. The health plan's denial may be based on injection
frequency; however, in some cases, changes in injection frequency are appropriate when deemed necessary by
the physician's clinical judgement. This variability of treatment schedule exists in medical studies validating the
safety and efficacy of this drug.
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 Eylea injection have been met. Therefore, we decided that the Plan has to
pay for the Eylea injection provided on January 28, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for cardiology services provided on January 1,2020 by an out of network (OON) provider.You asked the Plan to pay for cardiology services. You say that the member did not notify the office that he was not authorized to receive services in New York.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 cardiology services provided on January 1, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Medicare Part B prescription drugs
provided on February 17, 2020.
You asked the Plan to waive the coinsurance for Medicare Part B prescription drugs. You say that you disagree
with the charges because you were told that you would only owe a $35 copayment. 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 20%
coinsurance for Medicare Part B prescription drugs.
You received Medicare Part B prescription drugs on February 17, 2020. Therefore, you are responsible to pay
$2,710.88, which is less than the 20% coinsurance amount.
You have been asked to pay $2,710.88 for Medicare Part B prescription drugs. Medicare Part B prescription
drugs 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 Medicare Part B prescription drugs provided on February 17, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to you on December 13, 2019.
You asked the Plan to pay for the services. You say that the services were necessary. The Plan denied your
request. The Plan says this type of provider is not payable.
The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for
services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare program.
We looked at the file and Medicare rules. The requested provider is a licensed professional counselor. This type
of provider is not eligible to enroll in the Medicare program. Payment cannot be made to a provider who is not
enrolled in the Medicare program. 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 services
provided to you on December 13, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that IRF admission is necessary. The Plan denied your request. The Plan says Medicare coverage criteria for IRF admission are not met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the records do not indicate that there are significant, or complex medical/nursing issues that require an IRF level of care. The records show the enrollee is moderate to minimum assist for transfers and daily activities. The records do not show an IRF intensity level program is not warranted. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forMRI of the cervical spine (72141) provided on March 27, 2019.You asked the Plan to pay forthe MRI. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the documentation submitted does not support the service billed.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 72141 is magnetic resonance (eg, proton) imaging, spinal canal and contents, cervical; without contrast material.We find that CPT code 72141 is not supported in the medical record. Specifically, the record does not indicate than an MRI of the cervical spine was rendered on the billed date of service. Based on this information, we decided that Medicare rules for coverage of the MRI have not been met.Therefore, we decided that the Plan does not have to pay forMRI of the cervical spine (72141) provided on March 27, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ativan for the enrollee.You asked the Plan to pre-approve this drug. You say that the enrollee needs this to treat the enrollee's anxiety attacks.The Plan denied your request. The Plan says that this is not covered under Part B.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 Ativan for the enrollee.Benefits for this drug may be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on December 16, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes 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 December 16, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe programmable device evaluation provided on March 30, 2020.You asked the Plan to waive the copayment forthe programmable device evaluation. You say that you paid your $35 copayment at the time of the visit. You say you are being billed additionally by the nurse practitioner. 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 $35 copayment for diagnostic procedures and tests at an in-network specialist's office.You have been asked to pay a $35 copayment for the programmable device evaluation. The programmable device evaluation falls 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 forthe programmable device evaluation provided on March 30, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the specialist office visit provided on January 21, 2020.You asked the Plan to reduce the copayment for the specialist office visit. You say that the provider verified that they were an in-network provider.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 provider and professional services at an out-of-network specialist's office. You have been asked to pay a $50 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows that the provider is out-of-network.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 reduce the copayment for the specialist office visit provided on January 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physician services provided on February 6, 2020.
You asked the Plan to waive the copayment for the physician's services. You say that you only went to the office to get a different prescription and no other services were provided. The Plan denied your request. The Plan says the correct copayment has been applied to the claim.
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 $40 copayment for Vision Care, Medicare-covered exams to diagnose and treat diseases and conditions of the eye. You have been asked to pay $40 copayment for the physician's services. The physician's services falls within the Vision Care, Medicare-covered exams 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 physician services provided on February 6, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for outpatient surgery and outpatient rehabilitation provided on January 10, 2020.
You asked the Plan to waive the cost-sharing for outpatient surgery and rehab. You say that if you were in the hospital overnight your cost-share would only be $430, so you should not be charged this amount for a more affordable day surgery. The Plan denied your request. The Plan says the coinsurance amount you are being charged is correct.
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 outpatient surgery and $40 copayment for in-network rehab at an outpatient hospital facility. The allowed amount of the surgery is $15,319.72, resulting in a coinsurance amount of $3,063.94. You must also pay $40 copayment for the rehab service you received at this visit. Your total cost-sharing obligation is therefore $3,103.94. You have been asked to pay 20% coinsurance for outpatient surgery and $40 copayment for outpatient rehab. Outpatient surgery and outpatient rehab fall within the "Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" and "Outpatient Rehabilitation Services" benefit categories. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost-sharing for outpatient surgery and outpatient rehabilitation provided on January 10, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a ZARXIO self-administered injection for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says the request is a Part D drug, and the enrollee has no pharmacy benefit with the plan.
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 a ZARXIO self-administered injection for the enrollee.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the CT scan provided on March 8, 2020.
You asked the Plan to pay for the CT scan. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed 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. In this case, the CPT Code Manual definition of code 74177 is computed tomography, abdomen and pelvis; with contrast material(s). We find that CPT code 74177 is not supported in the medical record. Specifically, this code was billed with diagnosis code Z01.89 (Encounter for other specified special examinations). Z diagnostic codes can be used in any healthcare setting, but can only be reported as the principal diagnosis in the inpatient setting. Review of the file shows that these services were rendered in an emergency room, an outpatient non-routine setting. Therefore, this diagnosis code should be accompanied by the corresponding procedure code. Based on this information, we decided that Medicare rules for coverage of the CT scan have not been met. Therefore, we decided that the Plan does not have to pay for the CT scan provided on March 8, 2020.
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-ofnetwork
provider on October 3, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that
the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider
on October 3, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing rendered on November 6, 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 there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay forthe drug testing rendered on November 6, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Entyvio for the enrollee.
You asked the Plan to pre-approve Entyvio. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that they did not receive documentation supporting the medical necessity for a step therapy exception.
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 Entyvio. Our reviewer says that Entyvio is not medically reasonable and necessary for the enrollee in this case. The documentation does not support that the enrollee has tried and failed Stelara or that it would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Entyvio.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Entyvio have not been met. Therefore, we decided that the Plan does not have to pre-approve Entyvio for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on April 25, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. 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 April 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve office visit. You say that this provider treated you in the past and you find them helpful. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this provider is out-of-network with the Plan and you can be treated by an in-network provider.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.