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

We decided that the Plan does not have to pre-approve an interspinous stabilization device.
You asked the Plan to pre-approve the requested services. You say that the enrollee's condition has impacted
quality of life. The Plan denied your request. The Plan says it has not been shown to be safe and effective.
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 requested services. Our physician
reviewer found that interspinous process stabilization devices are experimental. More research is needed to
show safety and efficacy. Therefore, the requested services are not medically 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 requested services have not been met. Therefore, we decided that the Plan
does not have to pre-approve an interspinous stabilization device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient visit (G0463) provided on October 26, 2021 by
an out-of-network (OON) provider.
You asked the Plan to pay for the outpatient visit. You say that you would like reconsideration based on the
records submitted. The Plan denied your request. The Plan says this service was not urgent, emergent or
approved in advance.
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 visit (G0463) provided on October
26, 2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a transthoracic echocardiography (TTE)
with doppler provided on September 3, 2021.
You asked the Plan to waive the copayment for the TTE with doppler. You say that when you signed up with
the Plan you were informed there would be no copayments for services. The Plan denied your request. The
Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50
copayment for diagnostic radiology services received in a provider's office or free-standing facility.
You have been asked to pay a $50 copayment for the TTE with doppler. The TTE with doppler falls within the
Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you have
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have
to waive the copayment for a transthoracic echocardiography (TTE) with doppler provided on September 3,
2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the remote monitoring of physiologic parameter(s) (99454) provided on September 30, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the remote monitoring of physiologic parameters. You say that these services were medically necessary. The Plan denied your request. The Plan says OON care was not approved in compliance with the Plan's authorization procedure.

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 remote monitoring of physiologic parameter(s) (99454) provided on September 30, 2021, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for paclitaxel and fulvestrant injections
provided from July 14, 2021, to September 24, 2021.
You asked the Plan to waive the coinsurance for the injections. You say that you feel like you are being
charged twice for the same service. 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 Part B drugs, including chemotherapy drugs.
Drug Allowed Amount 20% Coinsurance
Paclitaxel - July 14, 2021 $1331.84 $266.36
$598.35 $119.67
Paclitaxel - July 21, 2021 $1341.49 $268.29
$588.70 $117.74
Paclitaxel - July 28, 2021 $1341.49 $268.29
$588.70 $117.74
Fulvestrant - July 29, 2021 $188.82 $37.76
$188.82 $37.76
Paclitaxel - August 12, 2021 $1331.84 $266.36
$598.35 $119.67
Paclitaxel - August 18, 2021 $1293.23 $258.64
$636.96 $127.39
Paclitaxel - August 25, 2021 $1273.92 $254.78
$656.27 $131.25
Paclitaxel - September 10, 2021 $1273.92 $254.78
$656.27 $131.25
Fulvestrant - September 10, 2021 $188.82 $37.76
$188.82 $37.76
Paclitaxel - September 17, 2021 $1273.92 $254.78
$656.27 $131.25
Paclitaxel - September 24, 2021 $1293.23 $258.64
$636.96 $127.39
Total: $3625.31
You have been asked to pay $3625.31, which is 20% of the allowed amount for the injections. The injections
fall within the Medicare Part B Prescription Drugs benefit category. This means that you have been asked to
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the
coinsurance for paclitaxel and fulvestrant injections provided from July 14, 2021, to September 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a computerized tomography (CT) scan
provided on September 27, 2021.
You asked the Plan to waive the copayment for a CT scan. You say that you have never paid a copayment for
this service. The Plan denied your request. The Plan says the proper 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 a $150
copayment for In-Network Diagnostic Radiological Services. The total amount allowed was $142.35 which is
less than the copayment amount of $150. Therefore, a copayment of $142.35 was charged.
You have been asked to pay a $142.35 copayment for CT scan. A CT scan falls within the Outpatient
diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the
copayment for a computerized tomography (CT) scan provided on September 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140), and panoramic x-ray (D0330) provided on August 24, 2021.
You asked the Plan to pay for the dental services. You say that you advised you only wanted services that would be covered. You say that you were advised to get a pre-estimate to ensure the services would be covered. You also say that you received a bill for this visit. The Plan denied your request. The Plan says that limited oral evaluation is not listed as a covered service. The Plan says that 1 panoramic x-ray or complete series x-ray is covered every 5 calendar years. The Plan also says that the frequency limit has been exceeded.
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.
Though the Plan offers a dental benefit in excess of Medicare coverage, the limited oral evaluation is not among those covered under this benefit. Additionally, the record shows that the frequency limit for the panoramic x-ray has been exceeded. The record shows that the Plan paid for a panoramic x-ray that you received on March 17, 2021. Additionally there is no pre-estimate on file for the services you received on the date of service in this case. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140), and panoramic x-ray (D0330) provided on August 24, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Praluent for the enrollee.
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your
request. The Plan says that this is not covered under Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Praluent for the enrollee.
Benefits for this drug 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 domiciliary or rest home visit for the evaluation and
management of an established patient (99335) rendered by the out-of-network (OON) provider on
September 15, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network
provider, without 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 service 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 this service. Therefore, we decided that the Plan
does not have to pay for the domiciliary or rest home visit for the evaluation and management of an established
patient (99335) rendered by the out-of-network (OON) provider on September 15, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolastin-C for the enrollee.
You asked the Plan to pre-approve Prolastin-C. You say that this is medically necessary. The Plan denied your request. The Plan says that the clinical value and effectiveness of Prolastin-C in the setting of the MZ confirmed phenotype has not been demonstrated in the peer-reviewed literature.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved 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 Prolastin-C. Our reviewer says that Prolastin-C is not medically reasonable and necessary for the enrollee. This patient has mild chronic obstructive pulmonary disease (COPD), with a normal FEV1 of 99% predicted. The A1AT phenotype is MZ, which is not associated with severe A1AT protein deficiency. The plasma level is 71.4, mildly reduced, but not severe enough to substantially impair anti-elastase activity. Commonly accepted criteria for infusion therapy are not met. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of Prolastin-C. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Prolastin-C have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolastin-C for the enrollee
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for an emergency room visit (99283) provided October 14, 2021.
You asked the Plan to pay for the emergency room visit. You say that the services were medically necessary.
The Plan denied your request. The Plan says the diagnosis code billed is for a dental service. Dental services
are non-covered.
Medicare generally does not cover dental services. The Plan follows the same rule.
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of
the enrollee's teeth or the structures directly supporting the enrollee's teeth. These are dental services that are
not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for an
emergency room visit (99283) provided October 14, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services (A0427 and A0425) provided on July 22, 2021.

You asked the Plan to pay for the ambulance services. You say that you would like reconsideration because the ambulance services were medically necessary. The Plan denied your request. The Plan says the member's claim history shows that they were registered inpatient on the billed date of service.

The Plan must follow Medicare rules. Medicare rules say that transportation to and from another hospital or freestanding facility to receive specialized diagnostic or therapeutic services not available at the facility where the patient is an inpatient is covered by the PPS. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ambulance services have not been met. Specifically, the record indicates that the member was registered inpatient on the billed date of service. Payment for the ambulance services is included in the payment to the facility and is the responsibility of the facility to any vendor. Therefore, we decided that the Plan does not have to pay for the ambulance services (A0427 and A0425) provided on July 22, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on September 24, 2021 by
an out-of-network (OON) provider.
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration based on the
documentation submitted. The Plan denied your request. The Plan says these services were not urgent,
emergent or approved in advance.
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 laboratory services provided on September 24,
2021 by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room services provided on July 20, 2021.
You asked the Plan to pay for the services provided. You say that the services rendered were medically
necessary. The Plan denied your request. The Plan says an appropriate diagnosis code was not billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate code.
The file shows that the services at issue were billed with a primary diagnosis code T50.905A, Adverse effect of
unspecified drugs, medicaments and biological substances, initial encounter. We looked at the file and the
rules. This type of code must be used in conjunction with an underlying condition code and must be listed
following the underlying condition. Based on this information, we decided that Medicare rules for coverage of
the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the
emergency room services provided on July 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist telehealth visit provided on
August 25, 2021.

You asked the Plan to waive the copayment for the specialist telehealth visit. You say that the appointment was
only a quick phone call. 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 $45
copayment for each specialist visit, including telehealth visits.

You have been asked to pay a $45 copayment for the specialist telehealth visit. The specialist telehealth 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 a specialist telehealth visit provided on August 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care (99233) provided on September
21, 2020.
You asked the Plan to pay for the subsequent hospital care. You say that you would like reconsideration
because timely filing guidelines have been waived during the public health emergency. The Plan denied your
request. The Plan says this claim was not filed timely.
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 record shows that a claim for the subsequent hospital care was not filed until October 21, 2021. This means
that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we
decided that the Plan does not have to pay for the subsequent hospital care (99233) provided on September 21,
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a continuous glucose monitor (K0553, K0554) provided
August 4, 2021.
You asked the Plan to pay for the continuous glucose monitor. You say that the items were medically
necessary. The Plan denied your request. The Plan says the documentation does not support the billed items.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a
physician order and proof of delivery.
The record does not contain relevant medical records which support medical necessity for the supplies provided
in this case. Insufficient clinical documentation was provided to support the continuous glucose monitor. The
record shows that the Plan made several attempts to obtain the necessary documentation without success.
Therefore, we decided that the Plan does not have to pay for a continuous glucose monitor (K0553, K0554)
provided August 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an urgent care visit provided on October 11, 2021.

You asked the Plan to waive the copayment for the urgent care visit. You say that the services should be covered. 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 Urgently needed services.

You have been asked to pay a $110 copayment for an urgent care 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 an urgent care visit provided on October 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit for the evaluation and
management of an established patient (99335) rendered by the out-of-network (OON) provider on June 30,
2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network
provider, without 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 service 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 this service. Therefore, we decided that the Plan
does not have to pay for the domiciliary or rest home visit for the evaluation and management of an established
patient (99335) rendered by the out-of-network (OON) provider on June 30, 2021.