Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from
September 23, 2019 to September 30, 2019.
You asked the Plan to pay for home health 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 are not covered as billed.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must
be completed for home health care services to be covered.
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that
Medicare rules for completing the claim for home health services have not been met. Specifically, the
submitted claim does not include the required FIPS code. Therefore, we decided that the Plan does not have to
pay for the home health services provided to the enrollee from September 23, 2019 to September 30, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an EGD on October 29, 2019.
You asked the Plan to waive the copayment for an EGD. You say that you disagree with 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 $295 copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers. You received an EGD on October 29, 2019. An EGD is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $295 copayment. You have been asked to pay a $295 copayment for an EGD. An EGD falls within the outpatient surgery and other medical 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 an EGD on October 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist services provided on July 17, 2019.You asked the Plan to waive the copayment for the specialist services. You say that you feel these charges are incorrect and you would like the Plan to reconsider your request.The Plan denied your request. The Plan says the enrollee received services provided by a specialist on July 17, 2019. The Plan states the correct copayment has applied per the enrollee's contract with the Plan.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $20 copayment for specialist services. We looked at the file, the Plan's contract and Medicare rules. The file shows the enrollee received services provided by a specialist on July 17, 2019. The enrollee has been asked to pay a $20 copayment for the specialist services. The specialist services fall within the Physician/Practitioner services benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan.Therefore, we decided that the Plan does not have to waive the copayment for the specialist services provided on July 17, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on November 5, 2019.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 and the referring provider are not network providers 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 November 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided from September
13, 2019 to
September 24, 2019.
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says
the enrollee must receive care from in-network providers with the exception of emergency or urgent care,
dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network
provider, which requires prior authorization from the plan.
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 from September 13,
2019 to September 24, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from October 16, 2019 to October 31, 2019.
You asked the Plan to pay for home health 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 are not covered as billed.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the submitted claim does not include the required FIPS code. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from October 16, 2019 to October 31, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on December 5, 2019.You asked the Plan to pay for the dental service. You say that you were under the impression that your cleaning, like your wife's, would be fully covered. You say that the office never advised that the cleaning would not be covered. You also say that you would have waived to have the cleaning when it would not be denied for frequency.The Plan denied your request. The Plan says periodontal maintenance is not a covered service.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, periodontal maintenance is not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on December 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve revision surgery to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve revision 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 revision surgery to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

e decided that the Plan does not have to pre-approvean oxygen concentrator and related items (E1390, E0443, E0431).You asked the Plan to pre-approvethe oxygen concentrator and supplies. You say that the oxygen equipment is medically necessary.The Plan denied your request. The Plan says coverage criteria has not been metThe Plan must follow Medicare rules. The rules say that for patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90%, there is a rebuttable presumption of non-coverage for home oxygen.  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 oxygen concentrator and supplies. Our reviewer says that the oxygen equipment is not medically necessary. Our physician reviewer found the record shows the enrollee has an oxygen saturation of 97% on room air. Supplemental oxygen is not indicated for the enrollee.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the oxygen concentrator and supplies have not been met.Therefore, we decided that the Plan does not have to pre-approvean oxygen concentrator and related items (E1390, E0443, E0431).
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for inpatient care provided from August 24, 2018 to September 22, 2018.You asked the Plan to pay for inpatient care. You say that this care was medically necessary.The Plan denied your request. The Plan says that these services were not authorized.The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. 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 inpatient care. Our reviewer says that the record shows that the enrollee was not stable for transfer during the dates of service at issue. Our physician reviewer found the enrollee was transferred from another facility on August 24, 2018 for non-surgical treatment of cholecystitis. He was not considered a surgical candidate. He became septic and required intensive care unit (ICU) admission and vasopressor therapy. He continued to have ongoing issuespost ICU transfer with exacerbation of chronic obstructive pulmonary disease, dysphagia and aspiration. He required IV antibiotics and multiple medical therapies. His condition stabilized and improved and he was felt medically stable for discharge to a skilled nursing facility on September 22, 2018. The review has determined that the member was not appropriate for transfer until stable for discharge to the skilled nursing facility.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient care have been met.Therefore, we decided that the Plan has to pay forinpatient care provided from August 24, 2018 to September 22, 2018.If the Plan does not agree withour 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from October 30, 2019 to November 28, 2019. You asked the Plan to pay for the skilled nursing services. You say that the services that the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee did not require any skilled services that could not have been provided in an alternate setting other than a 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 skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a 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 skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from October 30, 2019 to November 28, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on December 19, 2019.You asked the Plan to pay forthe orthoses. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items orderedand for the frequency of use. The record shows that documentation submitted did not indicate the provider discussed the need for the billed supply code, so the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to pay fora knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on December 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power operated vehicle.
You asked the Plan to pre-approve a power operated vehicle. You say that you have problems breathing and are unable to go do community The Plan denied your request. The Plan says there is no home evaluation or physician order.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The file does not show that you have a mobility deficit that impairs your participation in MRADLs, your condition cannot be improved by a walker, cane or manual wheelchair, or that you can safely operate the PMD being requested. The item at issue in this appeal is being requested for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan cover PMDs for use only outside the home. This means that
Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a power operated vehicle.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Fasenra injections provided on September 3, 2019, October 10, 2019 and November 7, 2019.
You asked the Plan to waive the coinsurance for the Fasenra injections. You say that you were not informed how expensive the injections would be. You say that you cannot afford the large bill. The Plan denied your request. The Plan says the coinsurance 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). The enrollee's contract with the Plan clearly says that enrollees must pay 20% coinsurance for each Medicare-covered Part B drug. Covered services include drugs that usually aren't self-administered by the patient and are injected or infused while you are getting physician, hospital outpatient, or ambulatory surgical center services. The enrollee has been asked to pay a total of $4,132.98 for the Fasenra injections.
The Fasenra injections fall within the "Medicare Part B prescription drugs" benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. The records show that the injections were provided at the hospital. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the Fasenra injections provided on September 3, 2019, October 10, 2019 and November 7, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided from August 6, 2019 to September 21, 2019. You asked the Plan to pay for the physical therapy services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
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 physical therapy 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 physical therapy services provided from August 6, 2019 to September 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the biopsy provided on December 18, 2019.You asked the Plan to waive the copayment forthe biopsy. You say that you were never in an operating room and that you had a quick biopsy done. 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$290 copayment per visit for Medicare-covered outpatient surgery in an ambulatory surgical center or hospital outpatient facility. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $290 copayment for the biopsy.You have been asked to pay a $189.62 copayment for the biopsy. The biopsy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows you were billed by the outpatient hospital.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 forthe biopsy provided on December 18, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Trikafta.You asked the Plan to pre-approve Trikafta. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested drug is not a covered 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 pre-approve Trikafta.Benefits for Trikafta 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe injection rendered on June 7, 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 procedure code A9579 is not supported.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 A9579 is injection, gadolinium-based magnetic resonance contrast agent, not otherwise specified (nos), per ml.We find that CPT code A9579 is not supported in the medical record. Specifically, the documentation supports that an injection of gadoteridol was performed and there is a more appropriate for these codes. 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 pay forthe injection rendered on June 7, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveTacrolimus 1mg capsule (J7507).You asked the Plan to pre-approveTacrolimus 1mg capsule. You say that the exception is needed.The Plan denied your request. The Plan says Part B medications do not qualify for tier exceptions.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 Tacrolimus 1mg capsule have not been met. Specifically, the requested drug is covered under Medicare Part B. This means that it is not eligible for a tier exception, as Medicare Part B Drugs are not subject to tier exceptions.Therefore, we decided that the Plan does not have to pre-approveTacrolimus 1mg capsule (J7507).