Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve intradialytic parenteral nutrition (IDPN).You asked the Plan to pre-approve the IDPN services. You say that the nutritional needs of the enrollee have been carefully considered and a patient specific formula to meet the enrollee's protein needs have been formulated based on the guidelines for ESRD patients with malnutrition. You say that the goal is for the enrollee to reach and maintain a serum albumin of 3.8-4.0 g/dL for at least three consecutive months.The Plan denied your request. The Plan says that Medicare rules only cover this type of treatment if the enrollee has a permanent impairment of the digestive tract where the enrollee would not be able to absorb or process nutrients by mouth. The Plan says that the records provided do not support that this is the case for the enrollee in question.The Plan follows Medicare rules. Medicare rules say that parenteral nutrition is 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 pre-approve the IDPN services. Our reviewer says that the criteria for coverage have been met. Our physician reviewer found the enrollee is severely malnourished. The outcomes in hemodialysis patients are affected by nutritional state. IDPN has the ability to improve nutritional status and potentially improve outcomes. The enrollee has failed standard intervention with RD counseling and dietary supplementation.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 IDPN services have been met.Therefore, we decided that the Plan has to pre-approve intradialytic parenteral nutrition (IDPN).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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee from December 3, 2019 to December 30, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the claim was billed with type of bill 323, which is not payable.
The Plan must follow Medicare rules. Medicare rules say that home health services must be billed correctly. The claim was not billed with the correct Type of Bill. 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 home health services provided to the enrollee from December 3, 2019 to December 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Purewick Urine Collection System.
You asked the Plan to pre-approve the Purewick Urine Collection System. You say that you are on hospice and have urinary incontinence. You say that Foley catheters have failed to work and still leak. The Plan denied your request. The Plan says urinary incontinence supplies are not covered as they are disposable , hygienic items that cannot be reused.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve a Purewick Urine Collection System.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe limited oral evaluation (D0140) provided on January 14, 2020.You asked the Plan to pay forthe dental service. You say that you have been dealing with medical issues caused by your dental problems for years. You say that you were referred to this provider by another in network provider.The Plan denied your request. The Plan says limited oral evaluations are covered once per plan year. The Plan also says that the frequency limit has been exceeded.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 and limited oral evaluations are a covered service, the frequency limit of 1 per plan year has been exceeded. The record shows that the Plan previously paid for a limited oral evaluation that you received on January 8, 2020.Therefore, we decided that the Plan does not have to pay forthe limited oral evaluation (D0140) provided on January 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe frames (V2020) and progressive lenses (V2781) and anti-reflective coating (V2750) purchased January 28, 2020.You asked the Plan to pay forthe vision services. You say that you verified with a plan representative that this reimbursement would be handled the same as dental. After the services the representative sent you the claim form for out-of-network vision services.The Plan denied your request. The Plan says enrollee's must receive their vision services from an in-network provider.Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when purchased from an in-network provider.We looked at the file and the Plan's rules. You must use a network provider for routine coverage including routine exam, retinal imaging and eyewear allowance. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pay forthe frames (V2020) and progressive lenses (V2781) and anti-reflective coating (V2750) purchased January 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on February 12, 2020.You asked the Plan to waive the copayment for the office visit. You say that you were informed this was a follow up for surgery and you wouldn't be charged. You say that this should be covered in full.The Plan denied your request. The Plan says the copayment applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for medical care or surgery services in an in-network specialty physician's office. You have been asked to pay a $40 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. There is no provision in the contract which indicates a copayment would be waived for services performed as a follow-up to a surgical procedure. 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 office visit provided on February 12, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for radiation therapy services provided by on July 27, 2018.
You asked the Plan to waive the coinsurance for radiation therapy services. You say that you are on a fixed income and cannot afford the cost. 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). Your contract with the Plan clearly says that you must pay 30% coinsurance for each out-of-network, Medicare-covered radiation therapy service. You have been asked to pay a total of $4,806.46 for the radiation therapy services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on February 13, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. You say that the provider felt the service was medically necessary for the enrollee's care. The Plan denied your request. The Plan says prior authorization is required, but not obtained.
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 OON services. Therefore, we decided that the Plan does not have to pay for the medical services provided on February 13, 2020 by an out of network (OON) provider.
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 the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.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 complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's current medical status and chronic medical conditions do not require intensive physician or nursing oversight in an IRF. The enrollee may benefit from additional multiple therapies, however the documentation does not indicate that this therapy must be in an IRF with an intensive level program.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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on February 4, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. You say that you didn't know the doctor was not in network. The Plan denied your request. The Plan says a prior authorization is required if you are seeking non-emergency 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 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 for the medical services provided on February 4, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forlaboratory testing provided on November 18, 2019.You asked the Plan to pay forlab test. You say that the Plan's prior authorization demand is not justified, and it was not feasible to obtain authorization.The Plan denied your request. The Plan says the denial of payment for this service is correct, because the documentation submitted does not support the Place of Service (POS) code billed on this claim.The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). We looked at the file and Medicare rules. The documentation submitted shows that the sample for this testing was taken in an office setting, therefore the Place of Service (POS) code 81 -indicating an independent laboratory setting -is not appropriate for this claim. Based on this information, we decided that Medicare rulesfor coverage of lab test have not been met.Therefore, we decided that the Plan does not have to pay forlaboratory testing provided on November 18, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Magnetic Resonance Imaging (MRI) of the spine (72146, 72158) provided January 20, 2020.
You asked the Plan to waive the coinsurance for the MRI. You say that the coinsurance should be waived. The Plan denied your request. The Plan says the correct cost-sharing was applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 50% coinsurance for out-of-network advanced imaging. You have been asked to pay a 50% coinsurance for the MRI. The MRI falls within the out-of-network advanced imaging 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 coinsurance for Magnetic Resonance Imaging (MRI) of the spine (72146, 72158) provided January 20, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-covered chiropractic services provided on October 23, 2019.
You asked the Plan to pay for the non-covered chiropractic 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.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the non-covered chiropractic services provided on October 23, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two resin-based composites provided on December 10, 2019.You asked the Plan to pay for the resin-based composites. You say that you were not informed prior to the services being received that you were only covered for two fillings.The Plan denied your request. The Plan says the benefits for this service had been satisfied and the frequency limitation had been exceeded.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, restorations are limited to two procedures per calendar year. The record shows that you received two resin-based composites on November 21, 2019 and your restorations benefit was then exhausted.Therefore, we decided that the Plan does not have to pay for the two resin-based composites provided on December 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient mental health services provided on February 3, 2020 to February 10, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the provided services. You say that you were told the services would be covered. The Plan denied your request. The Plan says the services are not a benefit of your 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 documentation does not show that the requested provider in this case is a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The documentation does not show that the services were provided by a qualified mental health provider. 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 the outpatient mental health services provided on February 3, 2020 to February 10, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from January 27, 2020 to February 13, 2020.You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you disagree with the charges because you feel that you were discharged from the first stay too soon and that you should only owe a $220 copayment.The Plan denied your request. The Plan says he 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 $220 copayment for days 1-5 for inpatient hospital care. You had an inpatient hospital stay from January 27, 2019 to February 13, 2019. Therefore, you are responsible to pay a $220 copayment for days 1-5 (January 27, 2019 to January 31, 2019). $220 (copayment) x 5 (inpatient days) = $1,100. You have been asked to pay the total copayment amount of $1,100 for an inpatient hospital stay. An inpatient hospital stay fallswithin the inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment foran inpatient hospital stay from January 27, 2020 to February 13, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient rehabilitation services provided December 19, 2019 to December 24, 2019.
You asked the Plan to waive the copayment for the inpatient rehabilitation services. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct cost-sharing was applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $295 copayment for days 1-5 for Inpatient Care. You have been asked to pay a $1475.00 copayment 5 days of inpatient rehabilitation services. 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 rehabilitation services provided December 19, 2019 to December 24, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hyalgan (J7321). You asked the Plan to pre-approve the Hyalgan. You say that this enrollee has a history of diabetic neuropathy. You also say that this medication is preferred due to the enrollee's diabetic state.The Plan denied your request. The Plan says the information submitted does not meet the Plan's medical necessity guidelines for coverage.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.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 Hyalgan. Our reviewer says that the coverage criteria for Hyalgan has not been met. Our physician reviewer found the provided medical records do not indicate that the enrollee has tried and failed the required drugs, Orthovisc and Monovisc. Our reviewer also found that the records do not indicate that the Plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for personal care services (T1019) provided on December 1, 2019 through December 7, 2019.
You asked the Plan to pay for the personal care services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the services billed are not covered under the member's Plan.
The Plan must follow Medicare rules. Medicare rules say that custodial care is not covered. Custodial care is personal care for a person who does not need ongoing care from trained medical or paramedical staff. We find that CPT code T1019 is not supported in the record. Specifically, the services at issue are personal or custodial care and custodial care is not a covered benefit under Medicare. Based on this information, we decided that Medicare rules for coverage of the personal care services have not been met. Therefore, we decided that the Plan does not have to pay for personal care services (T1019) provided on December 1, 2019 through December 7, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a chest x-ray (71046) provided January 28, 2020.You asked the Plan to pay for the chest x-ray. You say that the claim should be paid.The Plan denied your request. The Plan says the deductible has not been met.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. The contract with the Plan says that there is a $1000 deductible for Radiology Services. The item or service you asked the Plan to pay for falls within the benefit category Radiology Services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1000 deductible for Radiology Services. This cost sharing is a contractual obligation that had not been met at the time the chest x-ray was received on January 28, 2020.Therefore, we decided that the Plan does not have to pay fora chest x-ray (71046) provided January 28, 2020.