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

We decided that the Plan does not have to pay for the cone beam CT capture and interpretation for TMJ series, BIO-PAK electromyography, special bite management, and consultation provided on July 22, 2019 and July 29, 2019.
You asked the Plan to pay for the cone beam CT capture and interpretation, BIO-PAK electromyography, and special bite management. You say that these services are medical and not dental. The Plan denied your request. The Plan says these services are not covered 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. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. The documentation provided indicates that the diagnostic imaging and oral appliance provided are dental in nature, and are not Medicare covered services. There is not sufficient documentation to support that these are medical services that can be covered by Medicare. Therefore, we decided that the Plan does not have to pay for the cone beam CT capture and interpretation for TMJ series, BIO-PAK electromyography, special bite management, and consultation provided on July 22, 2019 and July 29, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF 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 Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee is ambulating more than 100 feet and tending to activities of daily living (ADLs) with minimal supervision. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs at this point are custodial and, as a practical matter, can be provided at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forhome infusion therapy (S9328) provided on September 28, 2019 through October 5, 2019.You asked the Plan to pay forthe home infusion therapy. You say that you would like reconsideration because per CMS, CPT code S9328 is valid.The Plan denied your request. The Plan says CPT code S9328 has a status code of I which is not valid for Medicare purposes.The Plan must follow Medicare rules. Medicare rules say that providersmust report services correctly. Providers must report services with the appropriate CPT code.We find that CPT code S9328 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code S9328 has a status code of I. This means thatCPT code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not been met.Therefore, we decided that the Plan does not have to pay forhome infusion therapy (S9328) provided on September 28, 2019 through October 5, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe esophageal function test provided on November 21, 2019.You asked the Plan to waive the copayment forthe esophageal function test. You say that you were informed it would be billed as an x-ray. You say that you were informedthe cost would be $50.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 $400 copayment for services provided in an outpatient hospital facility.You have been asked to pay $232.90, which is less than the standard $400 copayment for the esophageal function test. The esophageal function test falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The esophageal function test is considered a gastroenterology 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 forthe esophageal function test provided on November 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and laryngoscopy services provided on
September 9, 2019 by an out of network (OON) provider.
You asked the Plan to pay for these out of network services. You say that you would like the plan to reconsider
their denial. The Plan denied your request. The Plan says the services received are not a covered benefit when
provided by an out of 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 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 office visit and laryngoscopy services provided
on September 9, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xopenex HFA for the enrollee. You asked the Plan to pre-approve this drug. You say that the enrollee is stable on this medication. The Plan denied your request. The Plan says that this medication does not fall under Part B. 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 Xopenex HFA for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that an inpatient rehabilitation facility admission is medically necessary. The Plan denied your request. The Plan says that the enrollee does not meet criteria for coverage of an inpatient rehabilitation facility admission.
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 that the member's medical conditions appear stable. There are no complex wound care needs and no unaddressed medical issues. She does not require medical oversight of her condition at an acute hospital level of care. The member requires physical therapy for mobility and occupational therapy for remaining activities of daily living and adaptive equipment. She has a new unilateral lower extremity impairment without identified significant upper extremity impairment and does not require the intensity of an acute level rehabilitation therapy program. The member is limited by pain after her recent fall and likely by severity of her comorbid medical conditions. She would not be expected to be able to fully participate in or benefit from the required intensity of an acute rehabilitation therapy program. Additionally, an intensive rehabilitation therapy program would not significantly impact the member's condition differently compared with therapy provided at a less intense level. The member's care can be appropriately provided at a skilled nursing facility level. 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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wheelchair ramp (E1399).You asked the Plan to pre-approve a wheelchair ramp. You say that the requested item is necessary.The Plan denied your request. The Plan says the item is not primarily medical in nature. Therefore, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plan does not have to pre-approve a wheelchair ramp (E1399).
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approveskilled nursing facility (SNF) care.You asked the Plan to pre-approveSNF care. You say that skilled nursing facility care is medically necessary for the enrollee.The Plan denied your request. The Plan says that the enrollee does not meetcriteria for coverage of skilled nursing facility care.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the enrollee meets criteria for coverage of skilled nursing facility care. Our physician reviewer found that the enrollee does have documented skilled therapy needs. While the enrollee is to be non-weight bearing on her right lower extremity, skilled therapy for transfer training, strength training and occupational therapy is medically necessary and reasonable. It is not yet established that the enrollee has reached a plateau in function. Daily skilled services are required to establish a maintenance program or to prevent deterioration of the enrollee's condition. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted.Therefore, we decided that the Plan has to pre-approveskilled nursing facility (SNF) care.If the Plan does not agree with our decision,they can ask usto 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: Unfavorable

We decided that the Plan does not have to pre-approve Trigger Point Injections (20550, 20552, 20553).
You asked the Plan to pre-approve the injections. You say that the injections are medically necessary. The Plan denied your request. The Plan says rules for coverage were not met.
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 injections. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found repeated Trigger Point Injections are considered not medically necessary under Medicare rules. 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 injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Trigger Point Injections (20550, 20552, 20553).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for cardiac rehabilitation services provided from November 11, 2019 to November 29, 2019.You asked the Plan to waive the copayments for cardiac rehabilitation services. You say that you were told that the services would be covered.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 $20 copayment for cardiac rehabilitation services. You received cardiac rehabilitation services from November 11, 2019 to November 29, 2019 for a total of 8 services. Therefore, you are responsible to pay a $20 copayment per each visit. The total amount you owe is: $20 (copayment) x 8 (cardiac rehabilitation services) = $120. You have been asked to pay the total copayment amount of $120 for cardiac rehabilitation services. Cardiac rehabilitation services fall within the cardiac rehabilitation 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 copayments for cardiac rehabilitation services provided from November 11, 2019 to November 29, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued long term acute care hospital services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is currently undergoing treatment at an LTACH for chronic respiratory failure in the setting of inclusion body myositis. The enrollee has a tracheotomy. The enrollee has not been able to wean from the ventilator/respiratory support. The enrollee appears to require LTC for respiratory/ventilator management. Ongoing care at LTACH is not medically necessary or reasonable. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued long term acute care hospital services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic radiology services provided on October 4, 2019.You asked the Plan to pay for the diagnostic radiology 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 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 diagnostic radiology services provided on October 4, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the external defibrillator provided on October 18, 2019.You asked the Plan to waive the coinsurance for the external defibrillator. The Plan denied your request. The Plan says that the claim processed 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 20% coinsurance for Medicare-covered durable medical equipment. You have been asked to pay a 20% coinsurance for the external defibrillator. The external defibrillator falls within the Medicare-covered durable medical equipment 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 the external defibrillator provided on October 18, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy services coded S9328 provided from November 23, 2019 to November 30, 2019.You asked the Plan to pay forthe home infusion therapy services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not a covered benefit.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 S9328 is home infusion therapy, implanted pump pain management infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem.We find that CPT code S9328 is not supported in the medical record. Specifically, code S9328 has a status code of "I". A status code of I means that this code is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy services have not been met.Therefore, we decided that the Plan does not have to pay forthe home infusion therapy services coded S9328 provided from November 23, 2019 to November 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tertiary level referral for chemotherapy.
You asked the Plan to pre-approve the referral. You say that there are complex health issues that need to be followed by continued care by UCI doctors. The Plan denied your request. The Plan says the information does not show a need for a tertiary level of care.
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 referral. Our reviewer says that the requested referral is not considered medically reasonable and necessary in this case. Our physician reviewer found Keytruda can easily be administered by an in-network provider. 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 referral have not been met. Therefore, we decided that the Plan does not have to pre-approve a tertiary level referral for chemotherapy.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Lorazepam 2mg tablet medication.
You asked the Plan to pre-approve this medication. You say that you are requesting a reconsideration of the Plan's denial as it is medically necessary and beneficial for the enrollee's health to remain on this medication. The Plan denied your request. The Plan says this medication is not a covered benefit under the enrollee's contractual policy.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve the Lorazepam 2mg tablet medication.
Benefits for this medication 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 waive the copayment forthe ECG provided on November 20, 2019.You asked the Plan to waive the copayment forthe ECG. You say that you were informed there was a $0 balance.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 $5 per day for Medicare-covered tests. You have been asked to pay a $5 copayment for the ECG. The ECG falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract withthe 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 ECG provided on November 20, 2019.Your complaint about receiving conflicting informationis 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.