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

We decided that the Plan does not have to pre-approve bone marrow aspiration for the enrollee's spine surgery.
You asked the Plan to pre-approve bone marrow aspiration. You say that the enrollee's diabetes and osteopenia puts her at risk for graft failure. The Plan denied your request. The Plan says the services are not medically necessary as an adjunct to spinal fusion.
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 bone marrow aspiration. Our physician reviewer found bone marrow aspirate remains experimental. More research is needed to show safety and efficacy. Therefore, the requested services are not considered medically reasonable and necessary at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of bone marrow aspiration have not been met. Therefore, we decided that the Plan does not have to pre-approve bone marrow aspiration for the enrollee's spine surgery.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 enrollee was receiving oxygen. The enrollee's creatinine was improving. The enrollee was on oral antibiotics. The enrollee required minimal assistance with transfers and walking 70 feet with a front wheeled walker. The enrollee required minimal assistance with upper body activities of daily living and moderate assistance for lower body activities of daily living. The documentation does not support that the enrollee would be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. The enrollee's therapy needs can be met at a lower level of care. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from November 7, 2019 through November 24, 2019.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you cannot afford a copayment on the claim. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 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). Review of the file show that you received inpatient hospital care from November 7, 2019 through November 24, 2019. You are asked to pay a $350 copayment for the inpatient hospital care. Per your contract there is a $350 copayment per in-network inpatient hospital care admission. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital care from November 7, 2019 through November 24, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home infusion therapy rendered from November 17, 2019 to November 24, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit forhome infusion therapy services or supplies.We looked at the file and Medicare and the Plan's rules. Based on this information, we decided that Medicare and the Plan's rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay forthe home infusion therapy rendered from November 17, 2019 to November 24, 2019.Benefits for these servicesmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from November 29, 2019 through December 2, 2019 provided by an in-network provider. You asked the Plan to waive the copayment for inpatient hospital care. 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 2019 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). Review of the file shows that you were admitted as inpatient on November 30, 2019 and discharged on December 2, 2019. You were asked to pay a $500 copayment per day from November 30, 2019 through December 1, 2019, days 1-2 of your inpatient hospital care. You were discharged on December 2, 2019 and there was no copayment charge for the day of discharge. Per your contract there is a $500 copayment per day required for days 1-3 for in-network 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 inpatient hospital care from November 29, 2019 through December 2, 2019 provided by an in-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on December 26, 2019.
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says there is no authorization for this service from a non-contract provider.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 services at 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 subsequent nursing facility care provided on December 26, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for ER visits and a computed tomography (CT) scan provided from April 22, 2019 to May 1, 2019.
You asked the Plan to waive the copayments for ER visits and a CT scan. You say that you cannot afford the charges. 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 $90 copayment for emergency care. Your contract with the Plan also clearly says that you must pay a $200 copayment for CT scans. You received ER visits on April 22, 2019 and April 26, 2019. Therefore, you are responsible to pay a $90 copayment per each visit. The total amount you owe is: $180. You received a CT scan on May 1, 2019. Therefore, you are responsible to pay the $200 copayment. The total amount you owe is: $380. You have been asked to pay the total copayment amount of $380 for ER visits and a CT scan. ER visits fall within the emergency care benefit category. 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 copayments for ER visits and a computed tomography (CT) scan provided from April 22, 2019 to May 1, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe alveoloplasty in conjunction with extractions and two removals of residual tooth roots provided on August 21, 2019.You asked the Plan to pay forthe alveoloplasty and the additional two removals of residual tooth roots. You say that all of the enrollee's dental work was done at the same clinic with the same dentist.The Plan denied your request. The Plan says alveoloplasty is not a covered procedure. The Plan also says that the enrollee had four extractions, and two were already approved for payment.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, alveoloplasty is not among those covered under this benefit. The contract also says that extractions are limited to two procedures per calendar year. The record shows that you received four removals of residual tooth roots on August 21, 2019, two of which were paid for, and the enrollee's extractions benefit had been exhausted.Therefore, we decided that the Plan does not have to pay forthe alveoloplasty in conjunction with extractions and two removals of residual tooth roots provided on August 21, 2019.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a spinal electrical osteogenesis stimulator for the enrollee.You asked the Plan to pre-approve a spinal electrical osteogenesis stimulator. The Plan denied your request. The Plan says that that this is not medically necessary.The Plan follows Medicare rules. Medicare rules say that a spinal electrical osteogenesis stimulator is covered if the above criteria have been met.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 a spinal electrical osteogenesis stimulator. Our reviewer says that a spinal electrical osteogenesis stimulator is medically reasonable and necessary for the enrollee in this case. The enrollee underwent a C4-C6 anterior cervical discectomy and fusion on 2/4/20. A spinal osteogenesis stimulator was ordered for risk factors including multilevel fusion and current smoking status. In this case, Medicare coverage criteria have been met relative to a multilevel spinal fusion surgery. Our physician reviewer found that the enrollee's condition meets Medicare criteria for a spinal electrical osteogenesis stimulator.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 spinal electrical osteogenesis stimulator have been met.Therefore, we decided that the Plan has to pre-approve a spinal electrical osteogenesis stimulator for the enrollee.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation feature (E2300), and electrical connection (E2310) and a leg rest (K0108).You asked the Plan to pre-approvea power seat elevation feature, and electrical connection and a leg rest. You say thatthese items are medically necessary.The Plan denied your request. The Plan says these items are not covered as requested.The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature (E2300)isnon-covered because it isnot primarily medical in nature.If a wheelchair has an electrical connection device described by code E2310 or E2311 and if the sole function of the connection is for a power seat elevation or power standing feature, it will be denied as non-covered.Miscellaneous options, accessories, or replacement parts for wheelchairs that do not have a specific HCPCS code and are not included in another code should be coded K0108.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a power seat elevation feature, and electrical connection and a leg rest have not been met.Power seat elevation systems are not covered. Because the electrical connection requested is nor the power seat elevation system, it is also not covered under Medicare rules. The leg rest at issue has been requested with an inappropriate code.Therefore, we decided that the Plan does not have to pre-approvea power seat elevation feature (E2300), and electrical connection (E2310) and a leg rest (K0108).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Stiolto Respimat Inhalation Spray.You asked the Plan to pre-approve the Stiolto Respimat. You say that you would like reconsideration because this medication is medically necessary.The Plan denied your request. The Plan says this request is not covered under Medicare Part B because this medication is self-administered.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 Stiolto Respimat Inhalation Spray.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on September 30, 2019 by an out of network (OON) provider. You asked the Plan to pay for the physician services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan 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 for the physician services provided on September 30, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements and vitamins, including preparation, any strength, 74 to 100 grams of protein - premix (B4197), parenteral nutrition supply kit; premix, per day (B4220) and parenteral nutrition administration kit, per day (B4224) provided to the enrollee from October 9, 2019 through October 15, 2019.
You asked the Plan to pay for the parenteral nutrition. You say that the claim should be paid. The Plan denied your request. The Plan says the records do not support this service.
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 parenteral nutrition have not been met. Healthcare Common Procedure Coding System (HCPCS) B4197 (7 Units) remains not supported. The documentation submitted did not include a valid physician order/lab requisition or medical records (signed by the ordering physician); therefore, the billed code cannot be verified. It is noted multiple attempts were made to obtain additional information from the provider. Healthcare Common Procedure Coding System (HCPCS) B4220 (7 Units) remains not supported. The documentation submitted did not include a valid physician order/lab requisition or medical records (signed by the ordering physician); therefore, the billed code cannot be verified. It is noted multiple attempts were made to obtain additional information from the provider. Healthcare Common Procedure Coding System (HCPCS) B4224 (7 Units) remains not supported. The documentation submitted did not include a valid physician order/lab requisition or medical records (signed by the ordering physician); therefore, the billed code cannot be verified. It is noted multiple attempts were made to obtain additional information from the provider. Therefore, we decided that the Plan does not have to pay for parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements and vitamins, including preparation, any strength, 74 to 100 grams of protein - premix (B4197), parenteral nutrition supply kit; premix, per day (B4220) and parenteral nutrition administration kit, per day (B4224) provided to the enrollee from October 9, 2019 through October 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve back surgery to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve back surgery. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services can be provided by a network provider. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve back surgery to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee from November 1, 2019 to November 18, 2019.You asked the Plan to pay for these services. You say that these claims should be paid.The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services 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 these services.Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee from November 1, 2019 to November 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora specialist office visit provided on November 11, 2019 by an out of network (OON) provider.You asked the Plan to pay fora specialist office visit. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that there is no network deficiency for these services and alternate network providers were found.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has topay 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 foraspecialist office visit provided on November 11, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete maxillary denture.You asked the Plan to pre-approve the complete maxillary denture. You say that your dentures are very loose, and your provider said that you need a replacement.The Plan denied your request. The Plan says this 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.Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea cone beam CT capture and interpretation (D0364).You asked the Plan to pre-approvethe cone beam CT capture and interpretation. You say that you do not have the money to pay for this and need implants due to medical and dental health issues.The Plan denied your request. The Plan says this 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.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. The Plan only covers intraoral x-rays, bitewing x-rays, and panoramic films.Therefore, we decided that the Plan does not have to pre-approvea cone beam CT capture and interpretation (D0364).