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

 We decided that the Plan does not have to pre-approve incontinence supplies.  You asked the Plan to pre-approve incontinence supplies. You say that you cannot control your urine output. The Plan denied your request. The Plan says this item is not a covered benefit.  The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable.   While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on November 15, 2020.  You asked the Plan to waive the copayment for the ER visit. You say that you feel as though insurance should cover this in full. The Plan denied your request. The Plan says you were charged this copayment correctly.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $110 copayment per visit for emergency room services.   You have been asked to pay a $110 copayment for the ER visit. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on November 15, 2020.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to reduce the copayment for wound debridement and compression services you received at an outpatient hospital clinic from December 6, 2019, to December 27, 2019.  You asked the Plan to reduce the copayment for the wound debridement and compression services at an outpatient hospital clinic. You say that you did not have surgery or any kind.  You said this should only be billed as an office visit. The Plan denied your request. The Plan says you were charged these copayments correctly. The Plan says that because the allowed amount for these services ($127.34 per date of service) is less than your copayment obligation, you are responsible for the fill allowed 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 $175 copayment per visit for outpatient hospital facility services.   You have been asked to pay a $175 copayment per visit for the wound debridement and compression services at an outpatient hospital clinic. Because these services occurred at an outpatient hospital facility, 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 wound debridement and compression services you received at an outpatient hospital clinic from December 6, 2019, to December 27, 2019.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Aranesp.  You asked the Plan to pre-approve Aranesp. The Plan denied your request. The Plan says the enrollee has not had a poor response to Retacrit for at least two consecutive months with appropriate dose adjustment.   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 Aranesp. Our physician reviewer found that the enrollee has a diagnosis of stage 4 chronic kidney disease and anemia in chronic kidney disease. The Plan requires a trial of Retacrit (Epoetin alfa-epbx) before they will approve the requested drug. The case file does not contain documentation of trial and failure of Retacrit. The documentation does not support that Retacrit would likely be less effective or would likely have adverse effects for the enrollee in this case.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have to pre-approve Aranesp.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve amlodipine besylate.  You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says self-administered drugs are not covered.  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 amlodipine besylate.   Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to reduce the copayment for the urgent care services you received on June 29, 2021.  You asked the Plan to reduce the copayment for the urgent care services. You say that the doctor you say was like a regular doctor.  You said that you went to a clinic and only needed to pay $10 when you were there.  You feel like your copayment should be reduced to $10. The Plan denied your request. The Plan says you saw this provider (who is not your primary care provider), for urgent care services, so the copayment applies 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 $45 copayment for for office visits with any provider (who is not your primary care provider) for urgently needed services.   Records show that you presented to this doctor for urgently needed care due to ear pain.  This doctor is not your primary care provider. You have been asked to pay a $45 copayment for the urgent care services. Your Evidence of Coverage says that the $45 copayment is owed if you see any provider other than your primary care provider for urgent care services. 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 urgent care services you received on June 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an upright walker.  You asked the Plan to pre-approve an upright walker. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.  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 an upright walker. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no evidence that the enrollee is unable to use a standard walker that is appropriately fitted or that the upright walker is more effective and safer for the enrollee's condition. Therefore, the upright walker exceeds the enrollee's medical need.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an upright walker have not been met. Therefore, we decided that the Plan does not have to pre-approve an upright walker.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for ambulance services you received on June 1, 2021.  You asked the Plan to waive the copayment for the ambulance services. You say that you were not aware of this copayment, and you cannot afford this amount. The Plan denied your request. The Plan says you were charged this copayment correctly.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $350 copayment per trip for ambulance services.      You have been asked to pay a $350 copayment for the ambulance services. 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 you received on June 1, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the computed tomography angiography (CTA) you had on August 10, 2021.  You asked the Plan to waive the copayment for the CTA. You say that you cannot afford this copayment. The Plan denied your request. The Plan says you were charged this copayment correctly.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for diagnostic radiology services.   You have been asked to pay a $250 copayment for the CTA. The CTA falls within the diagnostic radiology 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 the computed tomography angiography (CTA) you had on August 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the trigger point injection procedure you had at an outpatient hospital facility on March 19, 2021.  You asked the Plan to waive the copayment for the injection procedure. You say that your share of the cost is too high for this service. The Plan denied your request. The Plan says you were charged this copayment correctly.  The Plan says that because the allowed amount for this service ($247.76) is less than your copayment obligation, you are responsible for the full allowed 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 $295 copayment for services provided at an outpatient hospital facility.   You have been asked to pay a $295 copayment for the injection procedure. The injection procedure falls within the services provided at an outpatient hospital facility 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 trigger point injection procedure you had at an outpatient hospital facility on March 19, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the magnetic resonance imaging (MRI)of cervical, thoracic and lumbar spine.  You asked the Plan to pre-approve the MRI. You say that an MRI of complete spinal canal are needed to augment recent spinal x-rays to pinpoint exactly what changes have occurred in your body so appropriate treatment or specialist can be sought. The Plan denied your request. The Plan says the records do not support that the requested MRI is medically necessary.  The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 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 the MRI. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation of abnormal physical exam findings or failure of conservative therapy. There is no specific clinical rationale for the requested MRI of the cervical, thoracic and lumbar spine. The review has determined that the requested MRI is not medically reasonable or necessary.  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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve the magnetic resonance imaging (MRI)of cervical, thoracic and lumbar spine.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the surgical services (14301 and 14302) provided on January 13, 2021, and February 3, 2021.  You asked the Plan to pay for codes 14301 and 14302. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the medical records do not support the billing of codes 14301 and 14302.  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 14301 is Adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm. The definition of code 14302 is Adjacent tissue transfer or rearrangement, any area; each additional 30.0 sq cm, or part thereof (List separately in addition to code for primary procedure).  We find that CPT codes 14301 and 14302 are not supported in the medical record. Specifically, there is no documentation of an adjacent tissue transfer or rearrangement of any area, 30.1 sq cm to 60.0 sq cm to support code 14301. Given that the primary procedure code is not support, add-on code 14302 is also not supported. Based on this information, we decided that Medicare rules for coverage of codes 14301 and 14302 have not been met. Therefore, we decided that the Plan does not have to pay for the surgical services (14301 and 14302) provided on January 13, 2021, and February 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the lanreotide acetate injection you received on July 29, 2021.  You asked the Plan to waive the coinsurance for the lanreotide acetate injection. You say that you have to have this injection every 4 weeks and you cannot afford this cost sharing. The Plan denied your request. The Plan says you were charged this coinsurance 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 Medicare Part B drugs.   You have been asked to pay 20% coinsurance for the lanreotide acetate injection. The lanreotide acetate injection falls within the Medicare Part B 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 lanreotide acetate injection you received on July 29, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the intravenous immune globulin (IVIG) injections you received on June 11, 2021.

You asked the Plan to waive the coinsurance for the IVIG injections. You say that you believe you had met your out-of-pocket maximum before these injections. The Plan denied your request. The Plan says you were charged this coinsurance correctly. The Plan says that you had not yet met the out-of-pocket maximum prior to the claim for these IVIG injections being processed.

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 drugs. 

You have been asked to pay 20% coinsurance for the IVIG injections. The IVIG injections fall within the Medicare Part B drugs benefit category. The Plan has provided evidence showing that you had not met your out-of-pocket maximum until after this claim processed. 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 intravenous immune globulin (IVIG) injections you received on June 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the diagnostic eye exam you had on May 13, 2021.  You asked the Plan to waive the copayment for the diagnostic eye exam. You say that these services should be covered because that is what insurance is for. The Plan denied your request. The Plan says these services were covered, but you are responsible for the applicable cost sharing.  The Plan says that you were charged this copayment correctly.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $50 copayment for diagnostic eye exams.    You have been asked to pay a $50 copayment for the diagnostic eye exam. 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 diagnostic eye exam you had on May 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

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

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies.

You asked the Plan to pre-approve a CGM and supplies. You say that this is medically necessary. The Plan denied your request. The Plan says that your doctor did not provide information that you are using insulin injection three or more times a day.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan. 

We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve incontinence supplies.  You asked the Plan to pre-approve incontinence supplies. You say that you have urinary incontinence. The Plan denied your request. The Plan says this item is not a covered benefit.  The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable.   While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the genetic testing provided on September 16, 2020.  You asked the Plan to pay for the genetic testing. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.  The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, however, 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. We find that payment for the lab services is not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regard to the physician's intent that the test be performed prior to services taking place. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on September 16, 2020.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on July 18, 2021.  You asked the Plan to waive the copayment for the ER visit. You say that you do not feel as though you should pay this copayment because after hours of investigating, the ER staff was unable to find anything wrong with you. The Plan denied your request. The Plan says you were charged this copayment correctly.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $75 copayment per visit for emergency room care.   You have been asked to pay a $75 copayment per visit for the ER visit. This copayment applies regardless of your satisfaction with the 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 emergency room (ER) visit you had on July 18, 2021.