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

We decided that the Plan does not have to pay forSelf-Administered drugs provided October 30 to November 1, 2019.You asked the Plan to pay forthe self-administered drugs. You say that the drugs should be covered.The Plan denied your request. The Plan says self-administered drugs provided while an outpatient are not covered under the Part B medical benefit.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 pay forSelf-Administered drugs provided October 30 to November 1, 2019. Benefits for the self-administered drugsmay be available under Medicare Part D.Contactthe Plan that administers Part Dbenefits for further information concerning any benefits and appeal rights.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve admission to a skilled nursing facility (SNF). You say that the requested
admission to a SNF is medically necessary. The Plan denied your request. The Plan says the requested
admission to a SNF does not meet criteria.
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 admission to a skilled nursing facility
(SNF). Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the
enrollee admitted to an acute care hospital on 2/27/2020 due to chest pain. Per enrollee she fell out of bed prior
morning but did not hit her chest. Pain started after this event. Pain not present when she is at rest and not
moving. Hospital stay complicated by nose bleeds requiring transfusions.
This enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a
skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a
SNF. The enrollee does not have a complex wound care or other SNF level skilled nursing need. This enrollee's
functional status does not require skilled therapy services with the specialized skill, knowledge and judgment
of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment
in a SNF. The enrollee does not require these skilled nursing or skilled therapy services (or a combination of
these services) on a daily basis. As a practical matter this enrollee does not require the necessary services on an
inpatient basis, in a skilled nursing facility setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of admission to a skilled nursing facility (SNF) have not been met. Therefore, we
decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a colonoscopy provided on September 6, 2019.
You asked the Plan to waive the copayment for a colonoscopy. You say that this should be covered as preventative. 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 $200 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. The medical records show that you received a colonoscopy on September 6, 2019 due to bloody stool. Therefore, the colonoscopy is considered diagnostic, not preventative, and you are responsible to pay the $200 copayment. You have been asked to pay a $200 copayment for a colonoscopy. A colonoscopy falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 colonoscopy provided on September 6, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on July 26, 2019.
You asked the Plan to pay for the psychotherapy services. You say that you did not know that you needed prior authorization as you had been receiving therapy services before. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.
The Plan must follow Medicare rules. Medicare rules say that a social worker is not eligible to participate in the Medicare program. We looked at the file and Medicare rules. The file shows that the psychotherapy services were provided. A social worker is not eligible to participate in the Medicare program. Therefore, we decided that the Plan does not have to pay for psychotherapy services provided on July 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided by an out-of-network provider on September 3, 2019.You asked the Plan to pay forthe services. The Plandenied your request. The Plan says the services were not authorized.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 providersonly 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 services at issue in this appeal. 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 forthe medical services provided by an out-of-network provider on September 3, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forself-administered drugs provided on November 1 and November 2, 2019. You asked the Plan to pay forthe self-administered drugs. You say that the drugs should be covered.The Plan denied your request. The Plan says self-administered drugs provided in the outpatient setting are not eligible for coverage underthe Part B medical benefit.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 pay forself-administered drugs provided on November 1 and November 2, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray provided on March 14, 2019 by an out of network
(OON) provider.
You asked the Plan to pay for an x-ray. You say that you would like this claim processed for payment. The
Plan denied your request. The Plan says no prior authorization was obtained for this service.
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 an x-ray provided on March 14, 2019 by an out of
network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe group therapy services (90853) provided on August 20, 2019. You asked the Plan to pay forthe group psychotherapy. You say that the services were medically necessary and you have seen this provider before.The Plan denied your request. The Plan says there are in-network providers who can provide the services at issue.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 forthe group therapy services (90853) provided on August 20, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forComputed Tomography (CT) of the head and brain (70450) provided on September 15, 2019. You asked the Plan to pay forthe CT scan. You say that services were medically necessary.The Plan denied your request. The Plan says a valid diagnosis was not listed on the claim.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 70450 is not supported in the medical record. Specifically, a secondary only diagnosis cannot be used as the primary diagnosis. Based on this information, we decided that Medicare rules for coverage of the CT scan have not been met.Therefore, we decided that the Plan does not have to pay forComputed Tomography (CT) of the head andbrain (70450) provided on September 15, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay foran X-ray of the skull (70250) provided on November 29, 2019.You asked the Plan to pay forthe X-ray. You say that services were medically necessary.The Plan denied your request. The Plan says the claim was submitted incorrectly.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 70250 is not supported in the medical record. Specifically, the incorrect modifier was billed. Without the correct modifier, the claim is aduplicate of 820193380221196. Based on this information, we decided that Medicare rules for coverage of the X-ray have not been met.Therefore, we decided that the Plan does not have to pay foran X-ray of the skull (70250) provided on November 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on August 30, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services were not authorized.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 services at issue in this appeal. 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 forthe medical services provided to the enrollee by an out-of-network provider on August 30, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for self-administered drugs provided October 16 to October 17, 2019 by the Medical Center.
You asked the Plan to pay for the self-administered drugs. You say that the drugs should be covered. The Plan denied your request. The Plan says self-administered drugs provided in the outpatient setting are not eligible for coverage under the Part B medical benefit.
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 pay for self-administered drugs provided October 16 to October 17, 2019 by the  Medical Center.
Benefits for the self-administered drugs 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a mechanical ventilator (CPT E0466).
You asked the Plan to pay for the mechanical ventilator. You say that The Plan denied your request. The Plan says the requested device is not reasonable and necessary because it is to be used as a ventilator to help the enrollee's breathing at various times of the day, due to lung disease.
The Plan follows Medicare rules. Medicare rules say that ventilators are covered for certain indications. 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 mechanical ventilator. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee has chronic obstructive pulmonary disease (COPD) with chronic hypercapnic and hypoxic respiratory failure. The enrollee may benefit from BiPAP support at night. Medicare does not cover a ventilator when used as BiPAP. Certain BiPAP devices are capable of providing the AVAPS mode of ventilation that has been ordered. The enrollee benefited from BiPAP in the hospital, and there is no evidence of BiPAP failure. A ventilator is therefore considered 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 mechanical ventilator have not been met. Therefore, we decided that the Plan does not have to pay for a mechanical ventilator (CPT E0466).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for dental services provided July 15, 2019 to October 15, 2019
You asked the Plan to waive the copayment for dental services. You say that the enrollee has a heart condition so the dental services are medically necessary and you feel that the services should be covered or the copay should be waived or changed. The Plan denied your request. The Plan says the correct cost share has been applied as the dental allowance has already been reimbursed.
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 any amount above the $150 dental allowance for dental services. The dental allowance has already been reimbursed on February 6, 2019. 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 dental services provided July 15, 2019 to October 15, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for panoramic x-rays (D0330) provided October 15, 2019.
You asked the Plan to pay for the dental services. You say that the provider knew you had Medicare but did not ask you what type of policy you had. They used the wrong code and should have known the correct procedure. The Plan denied your request. The Plan says this service is not covered under the benefits package
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. Services not listed under the description of benefits is not covered by the plan. 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 pay for panoramic x-rays (D0330) provided October 15, 2019.
Appeal type: Other
Decision: Partially Favorable

We decided that the Plan has to reimburse you for the frames. We decided that the Plan does not have to reimburse you for the progressive lenses. You asked the Plan to reimburse you for the progressive lenses and frames. You say that you were not aware the Plan required that this service must be provided in-network since in 2017 and you do not recall receiving information that terms for this benefit had changed. You say this prescription for eyeglasses followed cataract surgery which required you to obtain new eyeglasses. The Plan says that you must use a network provider for eyewear.We decided that the Planhas to reimburse you forthe framesprovided on July 22, 2019.The Plan follows Medicare rules. Medicare rules say that standard frames are covered. The Plan contract says post cataract eyewear is covered. The Plan contract does not say you must use an in-network provider for post cataract eyewear. We looked and thefile, Medicare rules and the Plan's rules. Medicare covers standard frames. The Plan says post cataract eyewear is covered. The Plan does not say you must use an in-network provider for post cataract eyewear. Therefore, we decided that the Plan has to reimburse you for the frames. We also decided that the Plandoes not have to reimburse you forthe progressive lenses.The Plan follows Medicare rules. Medicare rules say that progressive lenses(V2781) will be denied as non-covered.We looked at the fileand Medicare rules. Medicare does not cover progressive lenses. Therefore, we decided that the Plan does not have to reimburse you forprogressive lenses provided on July 22, 2019.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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider from July 27, 2019, to September 30, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services were not authorized.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 andpre-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 services at issue in this appeal. The Plan did not pre-approve the servicesat issue. We found noexception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider from July 27, 2019, to September 30, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for extraction (D7140) and add tooth to existing partial denture (D5650) provided January 23, 2019.
You asked the Plan to pay for the dental services. You say that the plan provides 2 oral exams a year and you feel that you should be reimbursed $33 for the cost of performing the oral exam before the extraction. The Plan denied your request. The Plan says the requested service is not covered under the plan benefits.
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. Services not listed under the Description of Benefits are not covered by the plan. 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 pay for extraction (D7140) and add tooth to existing partial denture (D5650) provided January 23, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the enrollee has ongoing complex medical needs due to acute on chronic hypercapnia and hypoxic respiratory failure with recent pneumonia. The enrollee requires close monitoring due to recent Coumadin toxicity. You say that the enrollee has completed her care at the short term hospital and that her ongoing complex medical needs require management in an LTACH setting.The Plan denied your request. The Plan says the guidelines for coverage have not been met. The plan says that the enrollee can safely receive the needed continued care in another setting.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found ongoing care needs include respiratory support with tracheostomy care, supplemental oxygen, surveillance laboratory studies, bariatric patient services. and therapy services. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified thatare available at the LTACH, that are not available at the current health care setting being offered by the health plan.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 LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.