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

We decided that the Plan does not have to pay for physical therapy provided by a chiropractor on May 21, 2021.

You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says therapy services are not covered in a chiropractic setting.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 

The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for physical therapy provided by a chiropractor on May 21, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chemotherapy to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve chemotherapy. You say that you have very aggressive cancer and want to be seen at this provider. 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 chemotherapy to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of nivolumab.
You asked the Plan to pre-approve nivolumab. You say that the enrollee's tumor burden is high suggesting that he would respond to immunotherapy, and you want to offer this instead of conventional chemotherapy. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because Medicare references do not support this combination use for the enrollee's diagnosis.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 nivolumab. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested use of nivolumab. Our physician reviewer found
this drug is not approved by the Food & Drug Administration for the enrollee's diagnosis. This use is not
supported by one of the major drug compendia or by clinical research that appears in a Medicare approved
medical journal.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of nivolumab have not been met. Therefore, we decided that the Plan does not
have to pre-approve use of nivolumab.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for prostate cancer screening; PSA (CPT code G0103) provided on April 20, 2021.
You asked the Plan to pay for the PSA. You say that PSA screening is one of the preventive services that is covered. The Plan denied your request. The Plan says they have paid the maximum amount covered by the Plan for this service.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. Review of the file shows that the Health Plan has paid for the PSA test (CPT code G0103) on August 25, 2020. Your 2021 EOC states that enrollees are entitled to the PSA test once every twelve (12) months. Therefore, you would not be eligible until the 12-month timeframe has passed. Therefore, we decided that the Plan does not have to pay for prostate cancer screening; PSA (CPT code G0103) provided on April 20, 2021.
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 May 3, 2021.

You asked the Plan to pay for these services. 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 had network providers available who could have provided 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 out of network physician services provided to the enrollee on May 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for CPAP (Continuous Positive Airway Pressure) supplies provided from May 13, 2021, through May 14, 2021.
You asked the Plan to waive the coinsurance for CPAP supplies. You say that the supplier said you needed a new machine, and they could not send you the requested supplies. You also say that, afterward, the supplier sent you the supplies you no longer needed. The Plan denied your request. The Plan says you have been asked to pay 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 20% coinsurance for durable medical equipment (DME) items. You have been asked to pay 20% coinsurance for CPAP supplies. Date of Service
Item
Allowed Amount
20% Coinsurance
May 13, 2021
A7034
$61.47
$12.29
A7035
$18.54
$3.71
A7037
$17.89
$3.58
A7038
$2.56
$0.51
May 14, 2021
A7039
$6.72
$1.34
A7035
$18.54
$3.71
A7037
$17.89
$3.58
A7038
$15.33
$3.07
TOTALS
$158.94
$31.79
CPAP supplies falls within the Durable Medical Equipment (DME) and Related 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 coinsurance for CPAP (Continuous Positive Airway Pressure) supplies provided from May 13, 2021, through May 14, 2021.
Your complaint about the provider's customer service is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided on April 8, 2021.

You asked the Plan to pay for this service. You say that this service should be covered by the Plan. The Plan denied your request. The Plan says you 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 had network providers available who could have provided 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 out of network physician services provided on April 8, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xifaxan tablets.
You asked the Plan to pre-approve self-administered drugs. You say that the enrollee is already established on this therapy and has received maximum benefit from its use. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.
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 Xifaxan tablets. Benefits for self-administered drugs 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient rehabilitation facility care provided on January 27, 2021, to February 13, 2021.
You asked the Plan to waive the copayment for inpatient rehabilitation facility care. You say that your claims for inpatient care have been divided into two stays. You also say you did not have an interruption in care from January 15, 2021, until you were discharged on February 13, 2021. The Plan denied your request. The Plan says the copayment 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 a $295 copayment per day, for days 1 to 6 for inpatient hospital care. Your contract with the Plan also clearly says that your inpatient cost share will begin on day one each time you are admitted or transferred to a specific facility type, including inpatient rehabilitation facilities, long term acute care facilities, inpatient acute care facilities and inpatient psychiatric facilities. You have been asked to pay a $295 copayment per day for inpatient rehabilitation facility care. The records show that you received inpatient hospital care from January 15, 2021, through January 27, 2021. The records also show that you were transferred to an inpatient rehabilitation facility on January 27, 2021, until February 13, 2021 which is the result of a new cost share outside of your initial inpatient hospital stay. The EOC confirms that $295 was the required copayment for this service, however, you were charged $884.89 because with this copayment, you met your in-network maximum out-of-pocket deductible amount of $5,900. Please note, that once this payment is made, you will have 100% coverage and will not have any out-of-pocket costs for the rest of the year when you see a network provider. 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 inpatient rehabilitation facility care provided on January 27, 2021, to February 13, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for CxBladder TM test (blood test for cancer markers) (CPT code 81479) provided to the enrollee on February 24, 2021.
You asked the Plan to pay for the testing. You say that the services were medically necessary. The Plan denied your request. The Plan says this is not covered. The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Your request is not a covered benefit because this test has been determined not to be clinically valid and is a non-covered test. Therefore, we decided that the Plan does not have to pay for CxBladder TM test (blood test for cancer markers) (CPT code 81479) provided to the enrollee on February 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient services provided on June 16, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the outpatient services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide 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 requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided 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 the outpatient services provided on June 16, 2021 by an out-of-network (OON) provider.
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 April 15, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization.
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 had network providers available who could have provided 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 out of network physician services provided to the enrollee on April 15, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a chest x-ray (71046) provided on May 28, 2021.
You asked the Plan to pay for the chest x-ray. You say that the services were billed correctly. The Plan denied your request. The Plan says the enrollee was inpatient status at the time of service.
The Plan must follow Medicare rules. Medicare rules say that as a general policy, the POS code assigned by the physician/practitioner for the PC of a diagnostic service shall be the setting in which the beneficiary received the TC service. We looked at the file and Medicare rules. The records show that the claim for the services in dispute was billed with a POS code of 22. The record indicates that the member was inpatient on the billed date of service. There is a more appropriate POS code for the billed service.
Based on this information, we decided that Medicare rules for coverage of the chest x-ray have not been met.
Therefore, we decided that the Plan does not have to pay for a chest x-ray (71046) provided on May 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the Magnetic resonance imaging (MRI) represented by code 70551 provided on May 18, 2021.
You asked the Plan to pay for code 70551. 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 as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. Review of the file shows the claim was billed with an inappropriate place of service 22 (outpatient). According to claims history, the enrollee was inpatient during this date of service per the claim, for dates of service May 17, 2021, through May 20, 2021. Therefore, we decided that the Plan does not have to pay for the Magnetic resonance imaging (MRI) represented by code 70551 provided on May 18, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex procedure.
You asked the Plan to pre-approve Vertiflex. You say that this treatment is considered safe and effective and is a safer alternative to a laminectomy or spinal fusion. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because Vertiflex is experimental/investigational.
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 Vertiflex. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental, more research is needed to show its 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 Vertiflex have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex procedure.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99213) provided on January 14, 2021.
You asked the Plan to pay for an office visit. You say that you have a Plan where you can see any doctor. The Plan denied your request. The Plan says they cannot issue payment for services received from a provider who has opted out of Medicare.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. The records confirm that the provider opted out of Medicare on December 31, 2005. Therefore, we decided that the Plan does not have to pay for an office visit (99213) provided on January 14, 2021
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 May 26, 2021.
You asked the Plan to waive the copayment for the ER visit. You say that your primary care doctor called you and told you to go to the ER because the urgent care center was closed. You say that your doctor assured you that you would not have to pay for this. 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 $50 copayment for emergency room services. You have been asked to pay a $50 copayment for the ER visit. This copayment applies regardless of the reason for your visit to the ER. 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 May 26, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Guardant360 testing provided on February 2, 2021.
You asked the Plan to pay for Guardant360 testing. You say that the services were provided, and payment
should be rendered. The Plan denied your request. The Plan says Medicare requires that Guardant360 testing be
reported with code 81479.
The Plan must follow Medicare rules. Medicare rules say that the Guardant360 testing is covered when certain
criteria are met. One unit of CPT code 81479 is used to report this testing.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay
for Guardant360 testing provided on February 2, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Vitamin D; 25 hydroxy (82306) provided on February 12, 2021. You asked the Plan to pay for Vitamin D; 25 hydroxy. You say that the service was provided, and payment should be rendered. The Plan denied your request. The Plan says the services is not a Medicare benefit for the listed diagnosis.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The test at issue in this appeal, Vitamin D; 25 hydroxy, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for Vitamin D; 25 hydroxy (82306) provided on February 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit provided on June 1, 2021.
You asked the Plan to waive the copayment for a specialist office visit. You say that the clinic did not say the doctor was out-of-network. The Plan denied your request. The Plan says the copayment applied was 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 an $80 copayment for per visit to an out-of-network specialist. You have been asked to pay an $80 copayment for a specialist office visit. Specialist 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 waive the copayment for a specialist office visit provided on June 1, 2021.