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

We decided that the Plan does not have to pay forthe capsule endoscopy provided to the enrollee on May 29, 2019.You asked the Plan to pay forthe endoscopy services. The Plan denied your request. The Plan says there was no indication for a wireless endoscopy.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 pay for the endoscopy services. Our physician reviewer found that the enrollee has colonic diverticulosis, colon tubular adenoma, dyspepsia, abdominal pain, and an elevated PSA. Neither the enrollee's EGD, colonoscopy, nor CT angiogram identified any clinical concerns or suspicions to warrant further evaluation. Therefore, the service was not medically necessary.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 endoscopy services have not been met. Therefore, we decided that the Plan does not have to pay forthe capsule endoscopy provided to the enrollee on May 29, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says the information indicates that maximum potential has been reached from the restorative therapy program.
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 the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not require continued skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment. You do not have a tracheostomy tube, enteral feedings, complex wound care or other SNF level skilled nursing need beyond the last covered day. Your functional status does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment beyond what was approved by the health plan. You do not require these skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" beyond the last covered day. As a practical matter, you do not require the necessary services on an inpatient basis, in a skilled nursing facility setting beyond what was approved by the health plan.
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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for a gym membership provided from January 1, 2018 to
November 1, 2018.
You asked the Plan to reimburse you for the gym membership. The Plan denied your request. The Plan says the claims were not submitted to the plan within the time allowed for filing.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service. The record shows that a claim for the gym membership was not filed until November 6, 2019. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to reimburse you for a gym membership from January 1, 2018 to November 1, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for computerized corneal topography (92025) provided October 9, 2019.
You asked the Plan to pay for computerized corneal topography. You say that please review the medical documentation and review for reconsideration of procedure code 92025 that denied as experimental and/or investigational procedure. The Plan denied your request. The Plan says experimental or investigational services are not covered.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Based on this information, we decided that Medicare rules for coverage of computerized corneal topography have not been met. Therefore, we decided that the Plan does not have to pay for computerized corneal topography (92025) provided October 9, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay forultrasounds (76705 and 76982) provided on November 11, 2019 by an out of network (OON) provider.You asked the Plan to pay forultrasounds. You say that these services were medically necessary.The Plan denied your request. The Plan says these services were not authorized.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 hasnetwork 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 thatthe Plan does not have to pay forultrasounds (76705 and 76982) provided on November 11, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to a long term acute care hospital (LTACH) for the enrollee for the enrollee.You asked the Planto pre-approvethe LTACH services. You say that this is medically necessary.The Plandenied your request. The Plansaysthe enrollee is receiving appropriate inpatient acute care, and does not require transfer to the LTACH.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 review has determined that the enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. The enrollee does not have clinical conditions that cannot be appropriately treated in the current hospital, and there are no issues for which LTACH may offer a therapeutic advantage such as long-term complex wound care, prolonged ventilator weaning, or complex rehabilitation needs in the setting of ongoing acute medical needs.We looked at this physician's review, the file, andMedicare 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 Plandoes not haveto pre-approveadmission to a long term acute care hospital (LTACH) for the enrollee for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the Ice Machine (E1399) on June 20, 2019.
You asked the Plan to pay for the Ice Machine. You say that you had knee replacement surgery and to aide in your recovery, the surgeon recommended the ice machine to reduce swelling. You already paid $200 for the machine and you are seeking reimbursement. The Plan denied your request. The Plan says this item is not covered.
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 pay for the Ice Machine (E1399) on June 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the dialysis visits provided from May 13, 2019 to July 30, 2019.
You asked the Plan to waive the coinsurance for the dialysis visits. You say that you met your maximum out-of-pocket expense and these bills should be paid. 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 20% of the cost for dialysis received in a Medicare certified dialysis facility. You have been asked to pay a total of $136.32 for the dialysis visits. The dialysis visits fall within the "Services to treat kidney disease" benefit category. The record shows you had not yet met your maximum out-of-pocket expense. See chart below.
Dates of Service
Service
Allowed Amount
Coinsurance
Member Liability
May 13, 2019 to May 31, 2019
Dialysis
$150.86
20%
$30.17
June 1, 2019 to June 30, 2019
Dialysis
$242.27
20%
$48.45
July 1, 2019 to July 30, 2019
Dialysis
$288.51
20%
$57.70
Total
$136.32
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 dialysis visits provided from May 13, 2019 to July 30, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the myocardial perfusion imaging and regadenoson injection provided on October 28, 2019.
You asked the Plan to waive the cost share for the myocardial perfusion imaging and regadenoson injection. You say that you were informed you would only have a $30 copayment. You say that you should only be responsible for that. The Plan denied your request. The Plan says the cost share 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 $100 copayment for Medicare-covered nuclear medicine and 20% coinsurance for Medicare Part B-covered chemotherapy drugs and other Medicare Part B-covered drugs. You have been asked to pay a total of $150.69 for the myocardia
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on November 11, 2019 by an out of network (OON) provider.
You asked the Plan to pay for office services. You say that you are appealing. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and the Plan did not approve these services.
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 November 11, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve upper arch dental implants for tooth #'s 3 & 4.
You asked the Plan to pre-approve the dental implants. You say that you would like an exception made for these implants to be covered because you believe it is not your fault that you lost those teeth due to the provider's treatment. The Plan denied your request. The Plan says dental implants for the upper arch are not a covered benefit.
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 contract clearly states that dental implants are covered for the lower arch only. Tooth #'s 3 & 4 that you are requesting the implants for are located in the upper arch and are not covered. Therefore, we decided that the Plan does not have to pre-approve upper arch dental implants for tooth #'s 3 & 4.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to reimburse the enrollee forthe cranial hair prosthesis purchased on February 16, 2019.You asked the Plan to reimburse the enrollee forthe wig. You say that because of a medical condition the enrollee needed the wig and had a prescription. The Plan denied your request. The Plan says that a wig does not meet the CMS definition of durable medical equipment.Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules.The enrollee was referred for the wig by the provider. The provider is a contract provider. The file does not show that the plan provided notice that the wig would not be covered. Under Medicare rules, this means the wig is considered approved by the plan.Therefore, we decided that the Plan has to reimburse the enrollee forthe cranial hair prosthesis purchased on February 16, 2019.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 thenew information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran ultrasound provided on September 18, 2019.You asked the Plan to waive the copayment foran ultrasound. 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 $75 copayment for each radiological diagnostic service. You have been asked to pay a $75 copayment for an ultrasound. An ultrasound 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 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 ultrasound provided on September 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids purchased December 10, 2019.
You asked the Plan to pay for the hearing aids. You say that you are requesting reconsideration for the denial of reimbursement for the purchase of hearing aids. The Plan denied your request. The Plan says this service is not covered under the benefits package.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan covers for the cost of hearing exams but does not cover hearing aids. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids purchased December 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for doppler echocardiography provided on October 4, 2019.
You asked the Plan to waive the copayment for doppler echocardiography. You say that you disagree with the charges because you were told that you would not owe a copayment. 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 $100 copayment for each radiological diagnostic service. You have been asked to pay a $100 copayment for doppler echocardiography. Doppler echocardiography 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 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 doppler echocardiography provided on October 4, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Transcutaneous Electrical Nerve Stimulation (TENS) device
You asked the Plan to pre-approve the requested device. The Plan denied your request. The Plan says record of the enrollee being in an approved clinical study was not found.
The Plan must follow Medicare rules. Medicare rules say that a TENS device is only covered under certain medical indications. We looked at the file and Medicare rules. There is no documentation that shows the enrollee is enrolled in an approved clinical study. Based on this information, we decided that Medicare rules for coverage of the requested device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Transcutaneous Electrical Nerve Stimulation (TENS) device
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on September 20, 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 September 20, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe acute inpatient hospital care provided from October 29, 2019 through October 31, 2019.You asked the Plan to pay foracute inpatient hospital care. You say that the stay was medically necessary.The Plan denied your request. The Plan says the stay is not medically necessary.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the medical records provided indicate that the admitting physician expected the enrollee's admission to span two midnights. Care provided to the enrollee was observation level. There were no advance interventions or complex medical conditions. The enrollee had no complaints at the time of admission. Inpatient services were not supported by the documentation. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met.Therefore, we decided that the Plan doesnot have to pay forthe acute inpatient hospital care provided from October 29, 2019 through October 31, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for infusion therapy (S9328) provided on February 5, 2019 through May 1, 2019.
You asked the Plan to pay for the infusion therapy. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says S codes are not payable by Medicare.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We 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 that CPT code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for infusion therapy (S9328) provided on February 5, 2019 through May 1, 2019.