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

We decided that the Plan does not have to pre-approve a power wheelchair and accessories for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says there is no documentation of a mobility limitation that significantly impairs ability to
participate in MRADLs.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.
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 services. Our reviewer says that the
requested services are not medically reasonable or necessary. Our physician reviewer found the documentation
reveals that this enrollee has a personal mobility deficit but it is not clear that this deficit impairs participation
in MRADLs or why the enrollee's mobility deficit cannot be helped by an appropriately fitted manual
wheelchair with assist of propulsion from caregivers. The documentation does not support that the requested
power mobility device will significantly improve MRADLs in the home.
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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a power wheelchair and accessories for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reimburse you forthe Zoster (shingles) vaccine provided on August 15, 2019.You asked the Plan to reimburse you forthe shingles vaccine. You say that you need the shingles vaccine because of medical conditions.The Plan denied your request. The Plan says the Zoster (shingles) vaccine is not covered under your Medicare Part B benefit.In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the shingles vaccine.Therefore, we decided that the Plan does not have to reimburse you forthe Zoster (shingles) vaccine provided on August 15, 2019.Benefits for the shingles vaccinemay be available under Medicare Part D.Contactthe 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 the services provided on May 22, 2020,
through June 10, 2020.

You asked the Plan to waive the copayment for the services. You say that you are appealing your cost-share
responsibility for the services you received. The Plan denied your request. The Plan says the claim was
processed accordingly with your 2020 EOC benefits.

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 Plan sent us information regarding all the claims you questioned. Per the additional information you have
two claims in question: May 22, 2020, and June 8, 2020, through June 10, 2020.

Review of the file shows that you received emergency care services on May 22, 2020. You were asked to pay a
$90 copayment for the services. The health plan contract says that enrollees must pay a $90 copayment for
emergency care.

Furthermore, you received inpatient hospital care and were admitted on June 8, 2020 and discharged on June
10, 2020. You were asked to pay a $350 copayment per day from June 8, 2020, through June 9, 2020, days 1-2
of your inpatient hospital care. You were discharged on June 10, 2020, and there was no copayment charge for
the day of discharge. The health plan contract says that enrollees must pay a $350 copayment per day, days 1 to
5 for inpatient hospital care.

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 services provided on May 22, 2020, through June 10,
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveTotal Parenteral Nutrition (TPN) (CPT Code(s): B4185, B4199, B4189, B4224, B4193 and B4197).You asked the Plan to pre-approvethe services. You say that you asked for your plan to cover food by your vein during dialysis.The Plan denied your request. The Plan says the services are not covered for your condition.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 services have not been met. You are able to take food by mouth. Medicare says that food by vein is only covered when you cannot take food by mouth because your gut does not work.Therefore, we decided that the Plan does not have to pre-approveTotal Parenteral Nutrition (TPN) (CPT Code(s): B4185, B4199, B4189, B4224, B4193 and B4197).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forhome infusion therapy services provided from March 11, 2020, to September 2, 2020.You asked the Plan to pay forhome infusion therapy services. You say that the Plan should pay this claim.The Plan denied your request. The Plan says this procedure code is not valid for Medicare purposes.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 S9328 is home infusion therapy, implanted pump pain management infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem..We find that CPT code S9328 is not a valid code for Medicare purposes. S codes are unique temporary codes established by BCBSA and HIAA for private payor use. They are not valid nor payable by Medicare. Medicare uses another code for reporting of, and payment for, these services. Based on this information, we decided that Medicare rules for coverage of home infusion therapy management have not been met.Therefore, we decided that the Plan does not have to pay forhomeinfusion therapy services provided from March 11, 2020, to September 2, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe dental cleaning and periodic oral evaluation provided on August 5, 2020.You asked the Plan to pay forthe dental cleaning and periodic oral evaluation. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the dental services you received on August 5, 2020, the dental cleaning and the periodic oral evaluation are covered only once every year. The Plan says that you already received these services on February 3, 2020.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.We looked at the file, the Plan's contract and Medicare rules. The file shows that you received a dental cleaning and a periodic oral evaluation on August 5, 2020. The Plan's contract clearly says these services are only covered once per year. The file shows that you already received these services on February 3, 2020.Therefore, we decided that the Plan does not have to pay forthe dental cleaning and periodic oral evaluation provided on August 5, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit (99283) provided September 19, 2020. You asked the Plan to waive the copayment for the emergency room visit. You say that you did not see a physician at the emergency room so the copayment should be waived. The Plan denied your request. The Plan says the records show an emergency room visit was provided and therefore the correct copayment was applied. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 copayment for Emergency Care. You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls within the Emergency Care 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 emergency room visit (99283) provided September 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a vascular ultrasound (93978) and an ultrasound of the extracranial arteries (93880) performed on August 13 and August 14, 2020.
You asked the Plan to waive the copayment for a vascular ultrasound and an ultrasound of the extracranial arteries. You say that the requested services should have a $0 copayment. The Plan denied your request. The Plan says the correct copayment was applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $75 copayment for diagnostic procedures and tests performed by a provider other than your primary care physician. You have been asked to pay a $75 copayment for a vascular ultrasound and an ultrasound of the extracranial arteries. A vascular ultrasound and an ultrasound of the extracranial arteries fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay less than or equal to 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 vascular ultrasound (93978) and an ultrasound of the extracranial arteries (93880) performed on August 13 and August 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe Guardant360 testing provided on August 14, 2020.You asked the Plan to pay forthe testing services. You say that the provider ordered the testing to determine if therewas a more effective therapy to treat the enrollee's advanced cancer.The Plan denied your request. The Plan says there is a more appropriate code to describe the services provided.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that the testing at issue was not billed with a valid CPT code.Based on this information, we decided that Medicare rules for coverage have not been met.Therefore, we decided that the Plan does not have to pay forthe Guardant360 testing provided on August 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadditional manual wheelchair accessories (push handles and Neoprene impact guards).You asked the Planto pre-approvethe additional accessories. You say that this is medically necessary.The Plandenied your request. The Plansaysthese items do not serve a medical purpose.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  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 additional accessories. Our reviewer says that the requested accessories are not considered medically reasonable and necessary in this case. Our physician reviewer found these items do not serve a primarily medical purpose.We looked at this physician's review, the file, and Medicare rules. Based onthis information, we decided that Medicare rules for coverage of the additional accessories have not been met.Therefore, we decided that the Plandoes not haveto pre-approveadditional manual wheelchair accessories (push handles and Neoprene impact guards).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvescaling in the presence of generalized moderate or severe gingival inflammation -full mouth, after oral evaluation (D4346).You asked the Plan to pre-approvescaling in the presence of generalized moderate or severe gingival inflammation -full mouth, after oral evaluation. You say that the service is medically necessary.The Plan denied your request. The Plan says the service is not a covered benefit.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 requested items or services are not among those covered under this benefit. Specifically, the service requested is not listed in the Plan's benefit chart. This means the service is not a covered benefit under your plan.Therefore, we decided that the Plan does not have to pre-approvescaling in the presence of generalized moderate or severe gingival inflammation -full mouth, after oral evaluation (D4346).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay forthe emergency department visit coded 99285 provided on July 22, 2020.You asked the Plan to pay forthe emergency department visit. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services are not payable as billed.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT code 99285 is not supported in the medical record. Specifically, this procedure code was billed with diagnosis code Z11.59 (Encounter for screening for other viral diseases) as the primary diagnosis. The other diagnosis codes listed on the claim were S09.90XA (Unspecified injury of head, initial encounter_ and T07.XXXA (Unspecified multiple injuries, initial encounter). The encounter for screening for other viral diseases (diagnosis code Z11.59) should not be listed as the primary diagnosis for the services rendered.Based on this information, we decided that Medicare rules for coverage of the emergency department visit have not been met.Therefore, we decided that the Plan does not have to pay forthe emergency department visit coded 99285 provided on July 22, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe massage therapy provided on August 12, 2020.You asked the Plan to pay forthe massage therapy. You say that you were approved for massage therapy.The Plan denied your request. The Plan says you have exceeded your massage therapy benefit.The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist but Plans may offer this benefit therefore Plan rules apply.10 massage therapy visits were used and paid for. Therefore, we decided that the Plan does not have to pay forthemassage therapy provided on August 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an administration of influenza virus vaccine provided on October 15, 2020.You asked the Plan to pay for the administration of influenza virus vaccine. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they 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 thiscase is not a network provider with the Plan. The Plan did not pre-approve the servicesat issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for an administration of influenza virus vaccine provided on October 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea partial mandibular denture (D5214).You asked the Plan to pre-approvea denture. You say that the servicesare medically necessary.The Plan denied your request. The Plan says the enrollee has exhausted their plan benefit for this service.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 requested items or services are not among those covered under this benefit. Specifically, records indicate the enrollee received a partial denture on May 17, 2019. This means the enrollee has exhausted their plan benefit for this service and it is not covered.Therefore, we decided that the Plan does not have to pre-approvea partial mandibular denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe periodic oral evaluation, first intraoral periapical x-ray, additional intraoral periapical x-ray, bitewing x-rays, and prophylaxis provided on September 30, 2020 by an OON provider.You asked the Plan to pay forthe periodic oral evaluation, intraoral periapical x-rays, bitewing x-rays, and prophylaxis. You say that you do not agree with the denial because you were not advised that this provider is no longer in-network with your plan.The Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that this claim was processed correctly.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, you are responsible for the difference between the billed amount and allowed amount.Therefore, we decided that the Plan does not have to pay forthe periodic oral evaluation, first intraoral periapical x-ray, additional intraoral periapical x-ray, bitewing x-rays, and prophylaxis provided on September 30, 2020 by an OON provider
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe 3 additional intraoral X-rays (D0230) and the 2D oral/facial photographic image (D0350) provided on September 24, 2020.You asked the Plan to pay forthe 3 additional intraoral X-rays and the 2D oral/facial photographic image. You say that you believe these services should be free.The Plan denied your request. The Plan says the 2D oral/facial photographic image is not a covered service and you have exhausted your benefits for additional intraoral X-rays.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 does not provide coverage for 2D oral/facial photographic image. The Plan covers additional intraoral X-rays once per calendar year. We looked at the file and Medicare rules. The file indicates that the Plan has already paid for one additional intraoral X-ray which means the benefit for additional intraoral X-ray has been exhausted. Based on this information, we decided that the Plan's rules for coverage of the 3 additional intraoral X-rays you received have not been met.Though the Plan offers a dental benefit in excess of Medicare coverage, the 2D oral/facial photographic image isnot among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe 3 additional intraoral X-rays (D0230) and the 2D oral/facial photographic image (D0350) provided on September 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continued use of a continuous positive airway
pressure (CPAP) device.
You asked the Plan to pre-approve the continued use of a CPAP device.. You say that you were not able to
follow the 4-hour guidelines due to an ill-fitting mask and then another mask that leaked. You say that you
need a proper mask to be able to appropriately use the device. The Plan denied your request. The Plan says
there does not appear to be a clinical re-evaluation by the treating practitioner to determine the etiology of the
failure to responds to the PAP therapy, even by telemedicine or electronic means.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We looked at the file and Medicare rules. The records do not demonstrate that you have been using the CPAP
for at least 4 hours per night on 70% of the nights during a consecutive 30-day period, during the first 3 months
of initial usage. This means that the CPAP is not considered reasonable and necessary. Based on this
information, we decided that Medicare rules for coverage of the continued use of a CPAP device. have not
been met. Therefore, we decided that the Plan does not have to pre-approve the continued use of a continuous
positive airway pressure (CPAP) device.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveProlia 60mg/ml injections.You asked the Plan to pre-approveProlia. You say that Prolia is medically necessary.The Plan denied your request. The Plan says a trial of Zoledronic Acid is require before Prolia can be considered in the absence of any Osteoporotic fracture.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Prolia. Our reviewer says that Prolia is not medically necessary. Our physician reviewer found the record shows no trial of the plan preferred drug or any reason why the plan preferred drug would be unsafe or ineffective for the enrollee.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met.Therefore, we decided that the Plan does not have to pre-approveProlia 60mg/ml injections.