Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve a meal program service. 
You asked the Plan to pre-approve meal program service. You say that the enrollee did not know he could have received meals after discharge and would like to be able to receive them now. The Plan denied your request. The Plan says that the denial of authorization for these services is correct, because the enrollee was discharged from the hospital to a Skilled Nursing Facility (SNF) and is therefore not eligible for this program.
The Plan must follow Medicare rules. Medicare rules say that custodial care services such as help with meals are not covered by Medicare. The Plan has a supplemental meal program benefit that goes beyond Medicare's coverage. For this reason, the Plan's rules apply to this case. The Plan covers a meal program after an inpatient hospital stay for enrollees who have both diabetes and congestive heart failure and participate in the medical management Transitions of Care program. We looked at the file and the Plan's rules. This meal program service is being requested after an inpatient hospital stay and the enrollee has the necessary diagnoses to qualify for this benefit. The enrollee can participate in the Transitions of Care program and receive meal program service at $0 copayment per meal in accordance with the Plan's meals program benefit. The Plan contract does not clearly disclose that enrollees do not qualify for this program if they discharge to a nursing facility before discharging to home. Based on this information, we decided that the Plan's rules for coverage of meal program service have been met. Therefore, we decided that the Plan has to pre-approve a meal program service.
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: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Fasenra for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says that the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary.  
 
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 these services. Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee has chronic eosinophilic pneumonia and schizophrenia. She is unable to tolerate systemic steroids due to mood changes. Treatment with Fasenra is considered reasonable and medically necessary due to chronic recurrent eosinophilic pneumonia (CEP), with peripheral eosinophilia and consistent findings on imaging and bronchoalveolar lavage. She is unable to tolerate the traditional treatment of systemic steroids. Anti-eosinophilic biologic therapy is a reasonable alternative treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to preapprove Fasenra for the enrollee  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0652) and segmental pneumatic appliance (E0667).
You asked the Plan to pay for a pneumatic compression device and appliance. You say that please see the documentation supporting medical necessity and coverage. The Plan denied your request. The Plan says you have not had a failed 4 week trial of either E0650 or E0651. Since the pneumatic compressor is not covered, your request for the segmented appliance (E0667) will also not be covered.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0652) and segmental pneumatic appliance (E0667).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the stem cell injection rendered to you on April 2, 2019.
You asked the Plan to pay for these services. You say that you paid up front for the services and would like reimbursement. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that stem cell transplantation is covered for specific diagnoses only. We looked at the file and Medicare rules. The file shows that you received a stem cell injection for arthritis. This is not a diagnosis for which these services are covered by Medicare. Therefore, we decided that the Plan does not have to pay for the stem cell injection rendered to you on April 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered on September 23, 2019.
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 procedure code 96401 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 96401 is chemotherapy administration, subcutaneous or
intramuscular; non-hormonal anti-neoplastic.
We find that CPT code 96401 is not supported in the medical record. Specifically, the records show that a
denosumab injection was performed and there is a more appropriate code for these services. 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 for the services rendered on September 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on October 17, 2019.
You asked the Plan to waive the copayment for the office visit. You say that you were informed this was an annual physical. You say that you did not know you already had an annual. 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 $10 copayment for PCP office visits. You have been asked to pay a $10 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show that the office visit was for a follow up for dyslipidemia and gastroesophageal reflux. 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 October 17, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on November 5, 2019.
You asked the Plan to pay for the physician's 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 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 physician's services provided on November 5, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on November 17, 2019.
You asked the Plan to waive the copayment for the ambulance transport. You say that you are a part of an ambulance company. You say that you did not call this ambulance company. 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 $250 copayment per one-way trip by ground or air ambulance. You have been asked to pay a $250 copayment for the ambulance transport. The ambulance transport falls within the "Ambulance services" 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 the ambulance transport provided on November 17, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dmission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says chronic conditions are stable, and do not require physician oversight to manage.
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 rehab, LTC/ECF). 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 dmission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 31, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the ophthalmic services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the services rendered have been deemed not covered under the member's 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 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 October 31, 2019 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 October 10, 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 October 10, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the direct pulp cap (D3110) and resin-based composite
(D2394) on tooth #31 provided on October 24, 2019.
You asked the Plan to pay for the direct pulp cap and resin-based composite. You say that you changed dentists
and were covered before two years ago. The Plan denied your request. The Plan says direct pulp cap is not a
covered benefit. The Plan also says that the maximum allowance for the resin-based composite has been paid.
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, direct pulp cap (D3110) is not covered
under this benefit. The Plan contract clearly states that restorative services including 1 amalgam, resin, or
composite filling per tooth are limited to 1 per tooth every 3 years. The record shows that you received a resinbased
composite on tooth #31 on April 5, 2017 and your restorations benefit for tooth #31 is now exhausted.
Therefore, we decided that the Plan does not have to pay for the direct pulp cap (D3110) and resin-based
composite (D2394) on tooth #31 provided on October 24, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the CardioMEMS HF system for the enrollee.
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your request. The Plan says this is not covered under the current Medicare Category B Investigational Device Exemption Requirements.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the system. Our reviewer says that the requested system is not considered medically reasonable and necessary in this case. Our physician reviewer found in this circumstance therapy change based on data obtained from a CardioMEMs device has been demonstrated in only one trial to help reduce hospital readmission compared to standard medical therapy. Moreover, concerns have been raised about potential bias in this trial calling into question the results. Therefore the efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and not recommended in current guidelines for the treatment of heart failure. Medicare coverage crieria are not met, since the device should still be considered experimental and investigational. 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 system have not been met. Therefore, we decided that the Plan does not have to pre-approve the CardioMEMS HF system for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided to the enrollee from June 3, 2019 through June 9, 2019.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you are appealing the member's cost-share responsibility for the services the member received. The Plan denied your request. The Plan says the claim was processed accordingly with the member's 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file shows that the enrollee was admitted on June 3, 2019 and discharged on June 9, 2019. The enrollee was asked to pay a $180 copayment per day from June 3, 2019 through June 8, 2019, days 1-6 of their inpatient hospital care. The enrollee was discharged on June 9, 2019 and there was no copayment charge for the day of discharge. Per the enrollee's contract there is a $180 copayment per day required for days 1-7. 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 inpatient hospital care provided to the enrollee from June 3, 2019 through June 9, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for removal of lateral exostosis (D7471) provided on October 7, 2019 by an out-of-network provider.
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says you do not have out-of-network 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. The provider is not in-network and your EOC clearly states, you must visit a participating dental network provider to receive dental benefits. Furthermore, the Plan received a signed treatment plan from your dentist which indicates you acknowledged and accepted financial responsibility prior to receiving the dental services. Therefore, we decided that the Plan does not have to pay for removal of lateral exostosis (D7471) provided on October 7, 2019 by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on November 22, 2019 by an out of network (OON) provider.
You asked the Plan to pay for an office visit. You say that you did not know you were out-of-network. The Plan denied your request. The Plan says no prior authorization was 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 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 office visit provided on November 22, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the mammogram and digital breast tomosynthesis rendered to you on July 23, 2019.
You asked the Plan to waive the copayments for these services. You say that the services should be processed as screening with no copayment. The Plan denied your request. The Plan says the copayments were 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 $150 copayment for covered diagnostic radiology services in an outpatient department of a network hospital or facility and a $110 copayment for each covered x-ray in the outpatient department of a network hospital or facility.
The file shows that you had a diagnostic mammogram on July 23, 2019. The services were diagnostic and not screening in nature because they were performed to evaluate for breast pain. You have been asked to pay a $110 copayment for these services. These services fall within the covered x-ray in an outpatient department of a network hospital or facility benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.
The file shows that you received digital breast tomosynthesis on July 23, 2019. Your contract with the Plan states that enrollees must pay a $150 copayment for covered diagnostic radiology services in an outpatient department of a network hospital or facility. However, the Medicare allowed amount for these services was $23.13. Given that the allowed amount was less than the $150 copayment, you have been asked to pay $23.13 for these services.
The total amount you have been asked to pay for these services is $133.13. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the mammogram and digital breast tomosynthesis rendered to you on July 23, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide reimbursement for the sales tax applied to the cost for the seat lift mechanism purchased on August 19, 2019.
You asked the Plan to provide reimbursement for the sales tax. You say that you feel that you should be reimbursed for the total you paid. The Plan denied your request. The Plan says sales tax is not separately payable for Medicare covered services as the fee schedule amount includes sales tax.
The Plan must follow Medicare rules. Medicare rules say that separate payment cannot be made for sales tax. Therefore, we decided that the Plan does not have to provide reimbursement for the sales tax applied to the cost for the seat lift mechanism purchased on August 19, 2019.