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

We decided that the Plan does not have to pre-approve radiation treatment services with an out of network (OON) provider.
You asked the Plan to pre-approve the radiation treatment services with the provider. You say that the requested therapy is medically necessary. The Plan denied your request. The Plan says once the enrollee signs a Medicare approved clinical trial consent form, Original Medicare is responsible for covered clinical trial services furnished to beneficiaries enrolled in managed care plans.
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in Original Medicare and the plan cost-sharing for the same services.
In this case, you asked the Plan to pre-approve the radiation treatment services with the provider as part of a clinical trial. The Plan does not cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-approve radiation treatment services with an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for SNF services.
You asked the Plan to pay for the SNF services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the member did not require any additional skilled services that could not have been provided in an alternate setting other than an SNF.
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 pay for the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the member did not meet severity of illness or intensity of service criteria or an inpatient basis in an SNF 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 the SNF services have not been met. Therefore, we decided that the Plan does not have to pay for SNF services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay from January 14, 2019 to January 18, 2019 by the provider.
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you do not feel you should be responsible for the copayment based on the level of care you received. The Plan denied your request. The Plan says based on Medicare billing criteria, the claim was billed 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 $450 copayment each day for days 1-4 for inpatient hospital care. You have been asked to pay $1,800 for the inpatient hospital stay. $450 for 4 days' equals $1,800. 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 inpatient hospital stay from January 14, 2019 to January 18, 2019 by the provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two crowns (D2752).You asked the Plan to pre-approve the crowns. The Plan denied your request. The Plan says the crown benefit has a limit to two in a calendar year. The Plan also says that your history plus this request has gone over this limit.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, crowns (either D2750 or D2751 or D2752) are limited to 2 per 1 calendar year. The record shows that you received two crowns (D2752) on February 4, 2020 and your crowns benefit is now exhausted.Therefore, we decided that the Plan does not have to pre-approve two crowns (D2752).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency room services provided on June 14, 2019.
You asked the Plan to pay for the emergency room services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the place of service code 22 is inappropriate because the member was in the ER and never in outpatient care.
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. We find that the emergency room services are not supported in the record. Specifically, the out-of-network provider has not provided sufficient information or medical records to verify the service at issue. Based on this information, we decided that Medicare rules for coverage of the emergency room services have not been met. Therefore, we decided that the Plan does not have to pay for emergency room services provided on June 14, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient hospital services rendered to you on October 2, 2017.You asked the Plan to waive the copayment for these services. You say that the Explanation of Benefits showed zero copayment due.The Plan denied your request. The Plan says the copayment was 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 $275 copayment for in-network outpatient hospital services other than observation stays. Review of the file shows that you received outpatient hospital services on October 2, 2017. The contract with the Plan states that there is a $275 copayment for in-network outpatient hospital services other than observation stays. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. However, the Medicare allowed amount for these services was $267.48. Given that the allowed amount was less than the $275 copayment, you have been asked to pay $267.48 for these services. The file shows that the provider reimbursed you for the copayment via check.Therefore, we decided that the Plan does not have to waive the copayment for the outpatient hospital services rendered to you on October 2, 2017.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the ankle and foot orthoses to be provided by an out of network provider,
You asked the Plan to pre-approve the ankle and foot orthoses. You say that you can provide a more specialized care, and better fitting and more functional orthoses. The Plan denied your request. The Plan says they will approve the ankle and foot orthoses with an in-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 the ankle and foot orthoses to be provided by an out of network provider,
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the non-needle cannula type and syringe with needle for an external insulin pump (coded with A4230 and A4232).
You asked the Plan to pre-approve the infusion pump supplies as coded. You say that this is medically necessary and should be approved. The Plan denied your request. The Plan says the infusion pump supplies have been approved via code A4224 and A4225.
The Plan must follow Medicare rules. Medicare rules say that the codes A4224 and A4225 are used to describe all necessary supplies and the insulin reservoir for use with an infusion pump. The codes A4230 and A4232 are not valid for this purpose. In this case, the Plan has indicated that the codes A4224 and A4225 have been approved. The use of the codes at issue in this case is not valid. Reimbursement for these supplies is included in payment for A4224 and A4225. Therefore, we decided that the Plan does not have to pre-approve the non-needle cannula type and syringe with needle for an external insulin pump (coded with A4230 and A4232).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe complete maxillary denture and complete mandibular denture provided on December 11, 2019.You asked the Plan to pay forthe complete maxillary and mandibular dentures. You say that the initial provider had failed to provide you with acceptable new dentures. You also say that the Plan led you to believe the new dentist would be recognized due to the poor service provided by the previous dentist.The Plan denied your request. The Plan says you had exceeded your benefit limitation.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, complete dentures are limited to one upper complete and/or one lower complete denture every five years. The record shows that you received a complete maxillarydenture and complete mandibular denture on July 25, 2019 and your complete dentures benefit was then exhausted.Therefore, we decided that the Plan does not have to pay forthe complete maxillary denture and complete mandibular denture provided on December 11, 2019.Your complaint about your dissatisfaction with the initial provider, and being misled by the Plan, 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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe outpatient mental health services to be provided by an out of network (OON) provider.You asked the Plan to pre-approvethe out-of-network mental health services. You say that you have seen this doctor before and would like to continue.The Plan denied your request. The Plan says the services are not emergent and there are 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 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-approvethe outpatient mental health services 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 the medical services provided on August 9, 2019 by an out of network (OON) provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by an out-of-network provider without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The 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 medical services provided on August 9, 2019 by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for massage therapy provided from September 7, 2018 to May 7, 2019.
You asked the Plan to pay for massage therapy. You say that you should be reimbursed for these services. The Plan denied your request. The Plan says these services are not covered by Medicare or the Plan.
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, we decided that the Plan does not have to pay for massage therapy provided from September 7, 2018 to May 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for midazolam hydrochloride (J2250) provided on May 16, 2019.
You asked the Plan to pay for the midazolam hydrochloride. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the units 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 asked our coder 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 midazolam hydrochloride. Our reviewer says that CPT code J2550x10 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records submitted do not include documentation to validate that 10 units of Injection, midazolam hydrochloride, per 1 mg was administered on May 16, 2019. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the midazolam hydrochloride have not been met. Therefore, we decided that the Plan does not have to pay for midazolam hydrochloride (J2250) provided on May 16, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on November 20, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the laboratory 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 laboratory services provided on November 20, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on September 9, 2019.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 laboratory services. 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 laboratory services provided on September 9, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF) for the enrollee.You asked the Planto pre-approveIRF care. You say that this is medically necessary.The Plandenied your request. The Plansaysthere is no requirement for an intensive and coordinated interdisciplinary approach, including physician visits at least three times weekly.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 does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care (ex. SNF/SAR, outpatient rehabilitation).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 Plandoes not havetopre-approveadmission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a new standard manual wheelchair.
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied your request. The Plan says you already have a wheelchair that is less than five years old.
The Plan must follow Medicare rules. Medicare rules say that replacement of durable medical equipment cannot be covered before the end of the reasonable useful lifetime. The most recent wheelchair was provided in 2019. This is less than five years ago, which is the reasonable useful lifetime for this wheelchair. Based on this information, we decided that Medicare rules for coverage of the wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a new standard manual wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for oxygenator assembly and operation services (CPT 99190) provided to the enrollee on November 6, 2019.
You asked the Plan to pay for the services. You say that CPT code 99190 is for the setup and operation of the Heart Lung machine for the above patients open heart surgery. The Plan denied your request. The Plan says payment for this service is the responsibility of the facility to any vendor.
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 99190 is "Assembly and operation of pump with oxygenator or heat exchanger (with or without ECG and/or pressure monitoring); each hour." We find that CPT code 99190 is not supported in the medical record. Specifically, payment for this code is included in the payment to the facility. 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 pay for oxygenator assembly and operation services (CPT 99190) provided to the enrollee on November 6, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zioptan drops for the enrollee.You asked the Plan to pre-approve the drops. You say that this is medically necessary.The Plan denied your request. The Plan says the medication falls under Part D coverage.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 Zioptan drops for the enrollee.