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

We decided that the Plan does not have to pre-approveOxycontin for the enrollee.You asked the Plan to pre-approveOxycontin. You say that the enrollee has chronic back pain due to degenerative disk disease.The Plan denied your request. The Plan says that this medication 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-approveOxycontin for the enrollee.Benefits for Oxycontinmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forphysical therapy provided on December 13, 2019.You asked the Plan to waive the copayment forphysical therapy. You say that there was no mention of costs or copayments. You say that you were under the impression that insurance covered it.The Plan denied your request. The Plan says the copayment applied 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 $40 copayment for each in-network, Medicare-covered therapy visit.You have been asked to pay a $40 copayment for the physical therapyvisit. Physical therapy falls within the "Outpatient rehabilitation 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 forphysical therapy provided on December 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the breathing capacity test provided by, on October 29, 2019.
You asked the Plan to waive the copayment for the breathing capacity test. You say that you were advised that your PCP copayment was $0. You say that you were not informed of a diagnostic test copayment. The Plan denied your request. The Plan says the copayment applied 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 all other diagnostic procedures and tests. You have been asked to pay $41.22, which is less than the standard $50 copayment for the breathing capacity test. The breathing capacity test falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. Outpatient diagnostic tests are considered a separate service. 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 breathing capacity test provided by, on October 29, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for routine hearing services provided on July 1, 2019 by a non-participating provider.
You asked the Plan to pay for the routine hearing services. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says hearing aids and routine hearing services are not covered by your Medicare plan.
The Plan must follow Medicare rules. The rules say that Medicare does not cover hearing aids or related services. You have mandatory supplemental hearing benefits. However, you must have hearing services rendered by a TruHearing Provider. You have been advised to submit your claim to TruHearing for any reconsideration. Therefore, we decided that the Plan does not have to pay for routine hearing services provided on July 1, 2019 by a non-participating provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Melanoma testing provided to the enrollee on June 24, 2019.
You asked the Plan to pay for the testing services. You say that the intent was to use the test results to inform treatment decisions. The Plan denied your request. The Plan says more study is needed to prove that this testing is helpful in caring for, or improving melanoma other than uveal melanoma.
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 pay for the testing services. Our physician reviewer found the difficulty in embracing gene expression profiling as an independent predictor of outcome is illustrated by the inconsistency of results across studies aimed at defining the most predictive gene sets for melanoma. The lack of overlap in gene signatures identified as prognostic for melanoma is likely due substantial differences in study design and methodology. Furthermore, a high risk melanoma does not translate into a therapeutic intervention, as adjuvant immunotherapy with a PD1 inhibiter or yervoy is reserved for node positive stage III disease. Follow-up for Stage IIB-IV includes imaging every 3-12 months, whereas imaging not required for Stage IA-IIA. Follow-up is not dictated by Melanoma risk profile. Therefore, Melanoma testing is considered experimental investigational as to treatment and surveillance. 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 testing services have not been met. Therefore, we decided that the Plan does not have to pay for the Melanoma testing provided to the enrollee on June 24, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tier exception for Mycophenolic Acid DR 180 mg tablet medication (J7518).
You asked the Plan to pre-approve a tier exception for this medication. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says that the drug requested is covered under the Medicare Part B (medical) benefit. Tier exceptions are only possible for certain Part D drugs. A tier exception cannot be granted for the Part B medication.
The Plan must follow Medicare rules. Medicare rules say that tiered cost-sharing means a process of grouping Part D drugs into different cost sharing levels within a Part D sponsor's formulary.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a tier exception have not been met. Specifically, the record indicates that the drug at issue is being covered by the Plan under Medicare Part B. Part B drugs are not eligible for tier exceptions. Therefore, we decided that the Plan does not have to pre-approve a tier exception for the Mycophenolic Acid DR 180 mg tablet medication (J7518).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says that there are no noted daily skilled complex nursing or therapy needs.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9328) provided on December 17, 2019 through December 24, 2019.
You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration because CPT code S9328 is a valid code per CMS. The Plan denied your request. The Plan says CPT code S9328 has a status code of I which is invalid 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. We find that CPT code S9328 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code S9328 has a status code of I. This means that CPT code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9328) provided on December 17, 2019 through December 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Glucose Monitor and sensor.
You asked the Plan to pre-approve the Glucose Monitor and sensor. The Plan denied your request. The Plan says the items being requested are not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor. We looked at the file and Medicare rules. The type of CGM being requested is not approved by the FDA for use in place of a blood glucose monitor for making diabetes treatment decisions and is not considered therapeutic. Based on this information, we decided that Medicare rules for coverage of the Glucose Monitor and sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Glucose Monitor and sensor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental sedation.
You asked the Plan to pre-approve dental sedation. You say that you can't start radiation until your dental work is complete. The Plan denied your request. The Plan says the service is not covered.
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. Although the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve dental sedation.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular nerve ablation.
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are not medically necessary.
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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has continued knee pain. She had a diagnostic left genicular nerve block on January 29, 2020 that provided 70 to 80 percent pain relief for two to three weeks. Genicular nerve blocks and ablation are considered experimental/investigational in nature. The services are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve genicular nerve ablation.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an x-ray provided on December 23, 2019.
You asked the Plan to waive the copayment for an x-ray. You say that this should be considered post-surgery. You say that this should have no copayment. The Plan denied your request. The Plan says the correct copayment has been 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 $45 copayment for outpatient diagnostic tests/x-rays. You have been asked to pay a $45 copayment for an x-ray. Post-op appointments are still subject for cost sharing amounts; therefore, the correct copayment has been applied. An x-ray falls within the outpatient diagnostic tests/x-rays 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 x-ray provided by on December 23, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent hospital care (99231) and initial hospital care (99222) provided to the enrollee from October 28, 2019 through October 30, 2019.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says this service was billed incorrectly.
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. CPT Code 99222 was denied because it did not include the appropriate primary, first-listed or principal diagnosis, per the ICD Manual. According to the ICD Manual, a secondary only diagnosis cannot be used as the primary, first-listed or principal diagnosis for any procedure or service. Therefore, we decided that the Plan does not have to pay for subsequent hospital care (99231) and initial hospital care (99222) provided to the enrollee from October 28, 2019 through October 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the urgent care visit, the EKG, and the inpatient hospital stay provided from December 24, 2019 to December 25, 2019.
You asked the Plan to waive the copayments for the urgent care visit, the EKG, and the inpatient hospital stay. You say that you should not be responsible for the copayments. 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 per visit for urgently needed services, a $5 copayment for other outpatient diagnostic tests (e.g. EKG, and a $290 copayment for each day, days 1 to 5 for inpatient hospital care. You have been asked to pay a $50 copayment for the urgent care visit, a $5 copayment for the EKG, and a $290 copayment for inpatient hospital care. The urgent care visit falls within the "Urgently needed services" benefit category. The EKG falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The inpatient hospital stay falls within the "Inpatient hospital 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 copayments for the urgent care visit, the EKG, and the inpatient hospital stay provided from December 24, 2019 to December 25, 2019
Your complaint about your nurse practitioner's oversight 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids purchased on October 30, 2019 from a non-participating provider.
You asked the Plan to pay for the hearing aids. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says some hearing services are covered when they are received from a network hearing or hearing aid provider.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. The provider is not in-network and your EOC clearly states, some hearing services are covered when they are received from a network hearing or hearing aid provider. Therefore, we decided that the Plan does not have to pay for hearing aids purchased on October 30, 2019 from a non-participating provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the medical services you received on November 6, 2019 and December 4, 2019.
You asked the Plan to pay for the medical services. You say that you have a letter stating you were approved to see the provider for a year. The Plan denied your request. The Plan says that the provider opted out of Medicare.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules. The records show that the provider at issue has opted out of Medicare. However, you were provided an authorization after the provider's opt-out start date. The records also show that the plan was made aware of the providers opt-out decision more than a week before your first visit. It is reasonable to expect that those with active authorization would no longer be covered. The file does not show that the plan provided notice that the medical services would not be covered. Under Medicare rules, this means the medical services is considered approved by the plan. Therefore, we decided that the Plan has to pay for the medical services you received on November 6, 2019 and December 4, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve meals to be delivered to your home.
You asked the Plan to pre-approve home meals. You say that you can't get up to prepare meals. The Plan denied your request. The Plan says home health services do not cover home meal delivery.
The Plan must follow Medicare rules. The rules say that services for which the sole purpose is to enable the patient to continue residing in their home are excluded from home health coverage. We looked at the file, and Medicare rules. Cooking, shopping, and meals on wheels are services excluded from coverage. Therefore, we decided that the Plan does not have to pre-approve meals to be delivered to your home.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a bronchoscopy (31645) and intubation (31500) provided on August 29, 2019.
You asked the Plan to pay for a bronchoscopy and intubation. You say that these codes are supported by the records. The Plan denied your request. The Plan says the records do not contain documentation of these services.
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 31645 is bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with therapeutic aspiration of tracheobronchial tree, initial, and 31500 is intubation, endotracheal, emergency procedure. 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 pay for a bronchoscopy and intubation. Our reviewer says that CPT codes 31645 and 31500 are not supported. Our physician reviewer found while the provided reports indicate that the enrollee was intubated, there are no procedure notes documenting the intubation or the provision of a bronchoscopy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a bronchoscopy and intubation have not been met. Therefore, we decided that the Plan does not have to pay for a bronchoscopy (31645) and intubation (31500) provided on August 29, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay foran x-ray provided on December 9, 2019 by an out of network (OON) provider.You asked the Plan to pay foran x-ray. You say that your portable US and x-ray services are deemed emergent and are provided to patient who are non-ambulatory and are in a nursing home.The Plan denied your request. The Plan says the referring provider is out-of-network. The Plan says that no prior authorization was obtained.Medicare rules say that plans can require enrollees to get care from network providers. The contract withthe 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 has network providers available who can provide 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 foran x-ray provided on December 9, 2019 by an out of network (OON) provider.