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

We decided that the Plan does not have to pay for the Guardant360 panel rendered on December 30, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the claim was not billed correctly.
The Plan must follow Medicare rules. The rules say that the Guardant360 panel must be billed with procedure
code 81479.
The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of codes. 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 for the Guardant360 panel rendered on December 30, 2019.
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 February 2, 2020.
You asked the Plan to reduce the copayment for the specialist office visit. You say that this was a regular primary care physician visit for a sinus infection which should have a $10 copayment. 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $40 copayment for each specialist visit for Medicare-covered benefits. The enrollee has been asked to pay a $40 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 this provider is an infectious disease specialist.
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 reduce the copayment for the specialist office visit provided on February 2, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
You asked the Plan to pre-approve Prolia. 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.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Prolia. Our reviewer says that the documentation does not support that the requested drug is medically reasonable or necessary. Our physician reviewer found The documentation does not outline contraindications or reasons why bisphosphonates were not considered. Without the support of the documentation, Prolia is not approved as step criteria is not met. Therefore, the enrollee does not meet criteria for the requested drug.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for and waive the cost-sharing for office visits provided from May 14, 2018 to December 16, 2019.
You asked the Plan to pay for and waive the cost-sharing for office visits. You say that you were not told that this provider was out-of-network with the Plan, and the provider kept telling you that everything was okay and not to worry. The Plan denied your request. The Plan says the denial of payment for dates of service May 14, 2018 to November 26, 2018 is correct, because these claims were not submitted within the timely filling limit. The Plan also says that the cost-sharing amounts you are being charged are correct.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of 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 $1,000 deductible for out-of-network office visits in 2018, a separate $1,000 deductible for out-of-network office visits in 2019, and $50 copayment for each out-of-network specialist visit in 2019 after the deductible has been met. Your total cost-sharing responsibility is $1,195.78.
The record shows that the claim for dates of service May 14, 2018 to November 26, 2018 was not filed until December 17, 2019. This means that more than one calendar year from the dates of service had passed before a claim was filed. The total denied amount for these services is $2,100. You have also been asked to pay $1,000 deductible in 2018, $1,000 deductible in 2019, and $50 copayment for office visits. Office visits fall 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 pay for and waive the cost-sharing for office visits provided from May 14, 2018 to December 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the chemodenervation procedure and the Part B injection provided on October 29, 2019.
You asked the Plan to waive the cost share for the chemodenervation procedure and the Part B injection. You say that you were told you would not be responsible for any copayments for the procedure. 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 $150 copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges and 20% coinsurance for each Medicare-covered Part B drug. You have been asked to pay a $150 copayment for the chemodenervation procedure and $24.49 which is 20% of the allowed amount for the Part B injection. The allowed amount is $122.46. ($122.46 x 20% = $24.49). The chemodenervation procedure falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. The Part B injection falls 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 cost share for the chemodenervation procedure and the Part B injection provided on October 29, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee requires daily physician visits, intensive therapies, and a multidisciplinary treatment team. The Plan denied your request. The Plan says the records do not indicate the need for 24-hour nursing, frequent physician visits, or special equipment.
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 physician reviewer found that the enrollee was at minimal assist sit-to-supine, maximum assist for lower body dressing, standby assist for grooming, and ambulation with standby assist using a rolling walker. The complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's medical status does not currently require intensive physician and nursing oversight only in an IRF. The enrollee may benefit from physical and occupational therapy, but the documentation does not support that his endurance level can tolerate an intensive rehabilitation therapy program provided in an IRF. 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.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the laboratory work provided on August 8, 2020 and August 22, 2020.
You asked the Plan to waive the deductible for the laboratory work. You say that these blood tests were a part of the follow-up for a serious problem and should be covered by your policy. 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. Your contract with the Plan says that there is $975 deductible that applies towards out-of-network laboratory services. The laboratory services you asked the Plan to waive the deductible for falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $975 deductible that applies towards out-of-network laboratory services. Please note, there is no provision in the contract which indicates the deductible would be waived if services are performed as a follow-up to an emergency.
This cost sharing is a contractual obligation that had not been met at the time the laboratory work was received on August 8, 2019 and August 22, 2019. Therefore, we decided that the Plan does not have to waive the deductible for the laboratory work provided on August 8, 2020 and August 22, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for a specialist visit (99213) and injection (J3490) provided February 12, 2020.
You asked the Plan to waive the cost sharing for the specialist visit and injection. You say that the cost sharing should be waived. The Plan denied your request. The Plan says the correct cost sharing has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for specialist visits and a 20% coinsurance for Part B drugs. You have been asked to pay a $40 copayment for a specialist visit and a 20% coinsurance for an injection of a Part B drug, for a total enrollee responsibility of $81.60. 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 a specialist visit (99213) and injection (J3490) provided February 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the echocardiography, glucose monitoring office visits, x-ray and the diabetic shoes and inserts provided from October 2, 2019 through January 31, 2020.
You asked the Plan to waive the cost share for the echocardiography, glucose monitoring, office visits, x-ray and the diabetic shoes and inserts. You submitted your bills for review. You say that you are wondering why it cost this. The Plan denied your request. The Plan says the cost share applied correctly.
The rules say that a Cost plan must disclose in writing all benefits available under the Plan. The health plan contract says that enrollees must pay a $50 copayment per visit and 20% coinsurance for diabetes supply items and therapeutic shoes and inserts. You have been asked to pay a total of $245.39 for the echocardiography, glucose monitoring, office visits, x-ray and the diabetic shoes and inserts. The echocardiography, glucose monitoring, office visits and x-ray fall within the "Outpatient hospital services" benefit category. The diabetic shoes and inserts fall within the "Diabetes self-management training, diabetic 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 cost share for the echocardiography, glucose monitoring office visits, x-ray and the diabetic shoes and inserts provided from October 2, 2019 through January 31, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the pathology services (88305) provided on October 28, 2019.
You asked the Plan to pay for the pathology services. You say that the services were medically necessary and the lab relies on the hospital to verify coverage. The Plan denied your request. The Plan says the hospital and enrollee were notified prior to the service that the services at issue would be non-covered because they were non-emergent and network providers were available.
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 service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the pathology services (88305) provided on October 28, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an oxygen concentrator (E1390) provided February 14, 2020. You asked the Plan to waive the coinsurance for the oxygen concentrator. You say that the coinsurance should be waived or reduced. The Plan denied your request. The Plan says the correct coinsurance 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 20% coinsurance for Durable Medical Equipment. You have been asked to pay a 20% coinsurance for the oxygen concentrator. The oxygen concentrator falls within the Durable Medical Equipment 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 an oxygen concentrator (E1390) provided February 14, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee will benefit from services that cannot be accomplished at a lower level of care. The Plan denied your request. The Plan says the enrollee does not have complex wound care, or a medical complexity to support the need for a rehab physician 3 times a week.
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 physician reviewer found that the enrollee is at moderate assist for transfers, total assist for toilet transfers, and moderate assist for bathing and bed mobility. The complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's medical status and chronic medical conditions do not currently require intensive physician and nursing oversight only in an IRF. The enrollee may benefit from multiple therapies, such as physical and occupational therapy, but the documentation does not support that she requires this therapy on an intensive rehabilitation therapy program provided in an IRF. 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.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of ENTYVIO.You asked the Plan to pre-approve ENTYVIO. You say that you are appealing with records.The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because the enrollee has tried and failed this drug twice before and it is not clear why another trial of ENTYVIO would have different results.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 ENTYVIO. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested use of ENTYVIO. Our physician reviewer found the enrollee has tried several treatment regimens for her condition. Documentation states that the enrollee's symptoms are refractory to Remicade, Humira, and Vedolizumab. There is no discussion explaining a rationale for ENTYVIO after the documented failure of Vedolizumab. Without the support of the documentation, medical necessity is not determined.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 use of ENTYVIO.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided February 21, 2020 toFebruary 28, 2020.You asked the Plan to waive the copayment forthe inpatient hospital care. You say that you should only have to pay one inpatient copayment because you had two hospitalizations in a short period of time.The Plan denied your request. The Plan says while the two hospitalizations were only separated by a brief reduction in level of care, you were still admitted two separate times, so 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 $380 per day copayment for days 1 through 5 for Inpatient Hospital Care. You have been asked to pay a $1900 copayment ($380 per day) for the first 5 days of an inpatient admission. 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 forinpatient hospital care provided February 21, 2020 to February 28, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex spinal distraction device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says this device is considered experimental, investigational, and unproven for all indications.
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 device. Our reviewer says that the requested device is not considered medically reasonable and necessary in this case. Our physician reviewer found this device is considered experimental, and more research is needed to show safety and efficacy. 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex spinal distraction device for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveinpatient psychiatric hospital services beginning July 3, 2020.You asked the Plan to pre-approveinpatient psychiatric hospital services. You say that these services are medically necessary.The Plan denied your request. The Plan says that the records received show that the enrollee's condition has improved and the enrollee is no longer a threat to himself or others.The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may becovered 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 inpatient psychiatric hospital services. Our reviewer says that inpatient psychiatric hospital services are not medically reasonable and necessary for the enrollee. The enrollee was admitted to the acute inpatient psychiatric hospitalization on June 23, 2020 with Major Neurocognitive Disorder with Behavioral Disturbance. It does not appear that active treatment was taking place beyond the date in question. It does not appear that the services are reasonably expected to improve the patient's condition or for the purpose of diagnosis beyond the date in question. There is no individualized treatment plan however the entire chart is not present. It does appear that the records were supervised and evaluated by a physician. Based upon review the records provided for the admission of thispatient does not meet the criteria for continued acute inpatient mental health treatment for the dates in question of July 3, 2020 forward as this patient was not shown to be a danger to herself or others.