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

We decided that the Plan does not have to waive the copayment for an office visit provided on September 8,
2021.
You asked the Plan to waive the copayment for an office visit. You say that this was a routine visit, and you
should not owe a 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 a $5
copayment for primary care provider visits.
The medical records show that you received an office visit that went beyond an annual wellness exam on
September 8, 2021. Therefore, you are responsible to pay the $5 copayment.
You have been asked to pay a $5 copayment for an office visit. An office visit falls within the
physician/practitioner services, including doctor's office visits benefit category. This means that you have been
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have
to waive the copayment for an office visit provided on September 8, 2021.
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 you need rehabilitation to build strength in arms and legs. The Plan denied your request. The Plan says according to the available records, you are near preadmission baseline and do not meet all the required Medicare criteria for admission to an IRF.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for weakness. Medical problems are stable. There are no complex nursing or rehabilitation needs.
You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the patient has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the 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 IRF admission and services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance transportation provided on June
26, 2021.
You asked the Plan to waive the copayment for the ambulance transportation. You say that you were offered a
ride home by the ambulance crew and were not aware there would be a charge. 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 $220
copayment for each one-way ambulance trip.
You have been asked to pay $125.89, which is less than the $220 copayment for the ambulance transportation.
Ambulance transportation falls within the Ambulance Services benefit category. This means that you have been
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have
to waive the copayment for ambulance transportation provided on June 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve removal of residual tooth roots (D7250) for tooth #28.
You asked the Plan to pre-approve removal of residual tooth roots. You say that these services are medically necessary. The Plan denied your request. The Plan says the request for a removal of residual tooth roots (D7250) for tooth #28 is not medically necessary. The x-ray sent by the provider shows the crown of the tooth is still present.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers removal of residual tooth roots when the services are medically necessary and reasonable. 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 removal of residual tooth roots. Our reviewer says that the requested service is not medically necessary as coded Our physician reviewer found that
the radiographs provided indicate an essentially intact tooth with much coronal attrition which reduced the amount of the remaining crown structure. Code D7250 is reserved for situations where there is a residual root that requires bone removal to extract the fragment. In this instance, there is an entire tooth present with a worn-down clinical crown, indicating that there is more than a root to be removed. Code D7250 would not be applicable in this instance, and the tooth may be removable without any cutting of bone. If it is found on removal that bone did need to be removed to extract the tooth, it must be documented, and a surgical code would be considered. The requested code of D7250 does not meet clinical criteria. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of removal of residual tooth roots have not been met. Therefore, we decided that the Plan does not have to pre-approve removal of residual tooth roots (D7250) for tooth #28.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zynlonta.
You asked the Plan to pre-approve the Zynlonta. The Plan denied your request. The Plan says the conditions needed to approve this drug have not been met.
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 the Zynlonta. Our reviewer says that the elements of the coverage criteria are not satisfied and Zynlonta cannot be recommended. Our physician reviewer found the Food and Drug Administration (FDA) has not stated that the requested drug is indicated for the enrollee's condition. Our reviewer found that the Medicare approved cancer drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's specific clinical situation. Our physician reviewer also found that no literature from Medicare approved cancer journals were submitted for review. 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 Zynlonta have not been met. Therefore, we decided that the Plan does not have to pre-approve Zynlonta.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99214) provided on October 21,
2021, by an OON provider.
You asked the Plan to pay for the outpatient office visit. You say that you have been seeing this kidney doctor
for years. You also say that you were forced into this Plan. The Plan denied your request. The Plan says you do
not have OON benefits. The Plan also says that there was no indication any attempt was made to obtain prior
authorization for the OON services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan 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 office visit (99214) provided on
October 21, 2021, by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Testosterone Cypionate injection (J1071).
You asked the Plan to pre-approve the Testosterone Cypionate injection (J1071). You say that the enrollee has been on this medication since 2015. The Plan denied your request. The Plan says the enrollee's Plan does not cover outpatient prescription drugs.
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 Testosterone Cypionate injection (J1071).
Benefits for the Testosterone Cypionate injection (J1071) 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 pay for the annual physical (CPT code 99397) provided on July 16, 2021.
You asked the Plan to pay for the service. You say that the Plan should cover the office visit you received because you had called the Plan prior to the visit and were told that the services would be covered. The Plan denied your request. The Plan says they have no record of you contacting them prior to the date of service regarding coverage of annual physicals.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.
Routine annual physicals are not covered by Original Medicare. Please note that physicals are distinct from the Medicare-covered annual wellness visit benefit, which covers "an annual wellness visit to develop or update a personalized prevention plan based on your current health and risk factors," once every 12 months. Based on this information, we decided that Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not have to pay for the annual physical (CPT code 99397) provided on July 16,
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for CxBladder testing (0012M) provided on January 26, 2021.
You asked the Plan to pay for CxBladder testing. You say that Medicare now provides coverage for this testing. The Plan denied your request. The Plan says this testing is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that CxBladder test code 0012M is not covered by Medicare. We looked at the file and Medicare rules. This test is not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of CxBladder testing have not been met. Therefore, we decided that the Plan does not have to pay for CxBladder testing (0012M) provided on January 26, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy with lesion removal (45385) provided on June 15, 2021.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.
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 $300 copayment for each Medicare-covered outpatient hospital service, including observation, outpatient surgery or procedure.
You have been asked to pay a $300 copayment for the Medicare-covered outpatient surgery provided. The colonoscopy performed in this case was indicated as outpatient surgery as polyps were removed during this procedure. 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 colonoscopy with lesion removal (45385) provided on June 15, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Cxbladder test (CPT code 0012M) provided to the enrollee on March 10, 2021.
You asked the Plan to pay for the Cxbladder test. You say that the test was medically necessary. The Plan denied your request. The Plan says the service is considered experimental and investigational.
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 Cxbladder test have not been met. The rules say that non-coverage reaffirmed for CPT codes 0012M and 0013M for CxBladder. Therefore, we decided that the Plan does not have to pay for the Cxbladder test (CPT code 0012M) provided to the enrollee on March 10, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room services provided on August 7, 2021, and August 8, 2021.
You asked the Plan to waive the copayment for emergency room services. You say that one of the visits should be waived as they were for the same issue and were done so close to each other. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided.
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 for Emergency care.
You have been asked to pay a $110 copayment for two visits to the emergency room on August 7, 2021, and August 8, 2021, for a total cost-sharing of $220. Based on the Plan's contract, cost-sharing for ER is only waived if you are admitted as inpatient to the facility. 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 services provided on August 7, 2021, and August 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1832) provided on April 16, 2021.
You asked the Plan to pay for the knee orthosis. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code L1832 was not billed with the required modifier.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Claims lines billed with codes without a KX, GA or GZ modifier will be rejected as missing information. We find that CPT code L1832 is not supported in the record. Specifically, this claim was not billed with the appropriate modifier. Based on this information, we decided that Medicare rules for coverage of the knee orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1832) provided on April 16, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Cosentyx pen.
You asked the Plan to pre-approve the Cosentyx pen. You say that the enrollee has failed multiple agents. The Plan denied your request. The Plan says the requested drug is not a covered benefit under the enrollee's 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 Cosentyx pen.
Benefits for the Cosentyx pen 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: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency room services (99284) provided on August 21, 2021.
You asked the Plan to waive the copayment for the emergency room services. You say that the charges are unreasonable based on what was provided. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services rendered.
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 $90 copayment for Emergency care.
You have been asked to pay a $90 copayment for an emergency room 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 emergency room services (99284) provided on August 21, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy, 45 minutes with patient (CPT code 90834) provided to the enrollee on May 13, 2021.
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not supported by the records.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.
Evaluation and management by psychologists is covered by Medicare under the following conditions: Provider must attempt to consult the attending or primary care physician about the services furnished and document the consent or declination date to consultations, and the date of consultations in the patient's medical record. If consultation with the attending or primary care physician is unsuccessful, document in the patient's medical chart with the date and manner of notification to the physician does not consent If attempts to consult directly with the physician are not successful, to notify the physician, within a reasonable time, that he or she is furnishing services to the beneficiary. There was no documented contact with the attending/primary care physician. There is no referring physician listed on the claim. Based on this information, we decided that Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not have to pay for psychotherapy, 45 minutes with patient (CPT code 90834) provided to the enrollee on May 13, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the infrared therapy (97026) provided on July 29, 2021.
You asked the Plan to pay for the infrared therapy. The Plan denied your request. The Plan says this is a noncovered
service.
The Plan must follow Medicare rules. Medicare rules say that the use of infrared and/or near-infrared light
and/or heat, including monochromatic infrared energy, is non-covered for the treatment, including the
symptoms such as pain arising from these conditions, of diabetic and/or non-diabetic peripheral sensory
neuropathy, wounds and/or ulcers of the skin and/or subcutaneous tissues.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the infrared therapy have not been met. Therefore, we decided that the Plan does not have to pay
for the infrared therapy (97026) provided on July 29, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an onabotulinumtoxina injection (J0585) provided on July 14, 2021.
You asked the Plan to waive the coinsurance for the onabotulinumtoxina injection. You say that the services should be covered in full as the enrollee was not made aware of the charges beforehand. The Plan denied your request. The Plan says the co-insurance applied correctly based on the services provided to the enrollee.
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 20% coinsurance for Medicare Part B prescription drugs.
The enrollee has been asked to pay a 20% coinsurance for the onabotulinumtoxina injection (the allowed
amount for this service is $3,038, 20% of that is $607.60). The onabotulinumtoxina injections fall within the
Medicare Part B prescription drugs benefit category. 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 waive the
coinsurance for an onabotulinumtoxina injection (J0585) provided on July 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for observation care discharge day management (CPT code 99217) provided to the enrollee on July 14, 2021.
You asked the Plan to pay for the service. You say that the claim was inappropriately downcoded and it has been confirmed that the CPT code reduced by your office was coded and billed accurately. The Plan denied your request. The Plan says the qualifying code is not found in the enrollee's claims history.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. CPT code 99217, observation care discharge day management (This code is to be utilized to report all services provided to a patient on discharge from outpatient hospital "observation status" if the discharge is on other than the initial date of "observation status." To report services to a patient designated as "observation status" or
"inpatient status" and discharged on the same date, use the codes for Observation or Inpatient Care Services [including Admission and Discharge Services, 99234-99236 as appropriate.]), denied because the qualifying initial or subsequent observation care (99218-99220 or 99224-99226) has not been reported or identified. Based on this information, we decided that Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not have to pay for observation care discharge day management (CPT code 99217) provided to the enrollee on July 14, 2021.