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

We decided that the Plan does not have to pre-approve Privigen.You asked the Plan to pre-approve Privigen. You say that the medical records provided support the need for Privigen.The Plan denied your request. The Plan says when the enrollee is in a clinical trial, payment for care can and should be made by the original Medicare Administrative Contractor.The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in Original Medicare and the plan cost-sharing for the same services. The rules also say that the Plan cannot require prior authorization or approval for services provided as part of a clinical trial.In this case, you asked the Plan to pre-approve Privigen as part of a clinical trial. The Plan does not cover routine costs associated with qualifying clinical trials.Therefore, we decided that the Plan does not have to pre-approve Privigen
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pay for the SNF care provided from February 24, 2019 to February 28, 2019.
You asked the Plan to pay for the SNF care. You say that the enrollee required the skilled services of a licensed therapist and would not have progressed to their current level of function without this care. The Plan denied your request. The Plan says that the provider is not active on the Ohio Department of Medicaid file.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. We requested additional clarifying information from the Plan, but this information was not provided to us. Hence, the Plan has not substantiated their denial of payment in this case. Therefore, we decided that the Plan has to pay for the SNF care provided from February 24, 2019 to February 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on September 27, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says non-emergent services rendered by non-participating providers in non-participating facilities require prior authorization as outlined in the enrollee's EOC.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 forthe medical services provided to the enrollee by anout-of-network provider on September 27, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvethe CardioMEMS HF device for the enrollee.You asked the Planto pre-approvethe device. You say that this is medically necessary.The Plandenied your request. The Plansaysthere is no information showing a trial and failure of CMS-required conservative CHF treatment measures in the home, including fluid/electrolyte restriction and daily weights.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 device. Our reviewer says that the requested device 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 criteria are not met since the device should still be considered experimentalor 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 device have not been met.Therefore, we decided that the Plandoes not haveto pre-approvethe CardioMEMS HF device for the enrollee.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve a complete mandibular denture (D5120).You asked the Plan to pre-approve the complete mandibular denture. You say that you need dentures because the dentures you had made by a previous provider were not made properly. You also say that you cannot eat with the dentures you have.The Plan denied your request. The Plan says that the dental x-rays document that you have 3 lower jaw dental implants, which contraindicates a complete lower denture. The Plan also says that a complete lower denture cannot be fitted with dental implants.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 Plan covers complete mandibular dentures when the services are medically necessary and reasonable.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 complete mandibular denture. Our reviewer says that the service is reasonable and necessary. Our physician reviewer found there was no indication that implant attachments are to be used. Our reviewer found that the denture is to be placed over the implants which would provide added stability. Our physician reviewer also found that this service is reasonable and necessary to provide you with adequate masticatory function.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the complete mandibular denture have been met.Therefore, we decided that the Plan has to pre-approve a complete mandibular denture (D5120).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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on October 24, 2019.You asked the Plan to pay for the laboratory 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 laboratory services. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for laboratory services provided on October 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the shoulder orthosis provided on October 16, 2019 by an out of network provider.You asked the Plan to pay for the shoulder orthosis (L3670). You say that the Plan should pay this claim.The Plan denied your request. The Plan says you did not request 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 item at issue in this appeal. The Plan did not pre-approve the item at issue. We found no exception that would require the Plan to pay for this item.Therefore, we decided that the Plan does not have to pay for the shoulder orthosis provided on October 16, 2019 by an out of network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for services provided by provider on October 14, 2019.You asked the Plan to pay for ambulance services. You say that the Plan should pay this claim.The Plan denied your request. The Plan says they have confirmed with the other health plan that they are secondary payers.The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer.The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible for ambulance services until the primary insurer has denied the claim for these services.Therefore, we decided that the Plan does not have to pay for services provided by provider on October 14, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient admission for Hyper-CVAD therapy.You asked the Plan to pre-approve an inpatient admission for Hyper-CVAD therapy. You say that the clinical notes provided support the need for an inpatient admission. You say that the enrollee will require careful monitoring and prevention for tumor lysis syndrome, which will include continuous IV fluid administration and frequent laboratory draws. You say that this cannot be safely accomplished in an outpatient setting.The Plan denied your request. The Plan says the clinical administration of the chemotherapy agents support that they do not always require inpatient admission.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 an inpatient admission for Hyper-CVAD therapy. Our reviewer says that an inpatient admission is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is to receive chemotherapy. The provider is concerned that the enrollee may develop tumor lysis syndrome (TLS) as a side effect to the chemotherapy. While TLS is a potential side effect of chemotherapy, there is no guarantee that it will occur. Therefore,an inpatient hospitalization is not summarily required. The enrollee should start receiving the therapy as an outpatient, while being carefully monitored. Should complications occur, the enrollee can be hospitalized at that time.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an inpatient admission for Hyper-CVAD therapy have not been met.Therefore, we decided that the Plan does not have to pre-approve an inpatient admission for Hyper-CVAD therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on August 9, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says non-emergent services rendered by non-participating providers in non-participating facilities require prior authorization as outlined in the enrollee's EOC.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 to the enrollee by an out-of-network provider on August9, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe sling provided on September 13, 2018. You asked the Plan to pay forthe sling (A4565). You say that the Plan should pay this claim.The Plan denied your request. The Plan says you did not request 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 itemat issue in this appeal. The Plan did not pre-approve the itemat issue. We found noexception that would require the Plan to pay for this item.Therefore, we decided that the Plan does not have to pay forthe sling provided on September 13, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing amounts for the 10 fillings, the upper partial denture and the lower partial denture that you received on August 20, 2019.You asked the Plan to waive the cost sharing amounts for the dental services. You say that you relied on a plan representative's assurance that you had partial denture coverage. You say that you were given papers to sign but that you did not finish. You say that you informed the office staff that you only wanted your partials covered by your insurance. You also say that the provider's office signed you up for a loan to pay for the services that were not covered and that you did not approve of this.The Plan denied your request. The Plan says that fillings and partial dentures are listed as covered service. The Plan says resin fillings are subject to a $20 copayment. The Plan also says that partial dentures are subject to a $195 copayment.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 fillings and dentures are listed as covered, there are cost sharing amounts that apply. The Evidence of Coverage clearly shows that the services you received have applicable copayments. This is a contractual obligation you agreed to when you enrolled in the Plan's dental coverage.Therefore, we decided that the Plan does not have to waive the cost sharing amounts for the 10 fillings, the upper partial denture and the lower partial denture that you received on August 20, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the Osteogenesis stimulator provided on August 23, 2019.You asked the Plan to pay for the Osteogenesis stimulator. You say that the Plan should pay this claim.The Plan denied your request. The Plan says they are secondary payers.The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer.The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed you to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible for the Osteogenesis stimulator until the primary insurer has denied the claim for these services.Therefore, we decided that the Plan does not have to pay for the Osteogenesis stimulator provided on August 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fortraction therapy (97012) and a therapeutic procedure (97150) provided on April 24, 2019.You asked the Plan to pay forthe traction therapy and therapeutic procedure. You say that you would like reconsideration as the services rendered were medically necessary.The Plan denied your request. The Plan says manual manipulation of the spine to correct subluxation of the spine is the only chiropractic service that is 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 service at issue is not manual manipulation of the spine.Therefore, we decided that the Plan does not have to pay fortraction therapy (97012) and a therapeutic procedure (97150) provided on April 24, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9328) provided from November 15, 2019 to November 22, 2019.
You asked the Plan to pay for home infusion therapy. You say that that this is a valid code. The Plan denied your request. The Plan says this code is not valid for Medicare purposes.
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. Specifically, this code has a status indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this information, we decided that Medicare rules for coverage of home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9328) provided from November 15, 2019 to November 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible or outpatient lab tests provided on August 22, 2019 and November 14, 2019.
You asked the Plan to waive the deductible or outpatient lab tests. You say that you should not have a deductible for this. The Plan denied your request. The Plan says the correct deductible has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $185 deductible for outpatient diagnostic tests/laboratory. The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient diagnostic tests/laboratory. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $185 deductible that must be met first. This cost sharing is a contractual obligation that had not been met at the time outpatient lab tests was received on August 22, 2019 to November 14, 2019. The total amount you are being asked to pay is $183 ($115.51 + $67.49 = $183). Therefore, we decided that the Plan does not have to waive the deductible or outpatient lab tests provided. on August 22, 2019 and November 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the cost share for the medical eye exam provided on August 16, 2019.You asked the Plan to reduce the cost share for the medical eye exam. You say that you were told you would only have to pay $30 for the eye visit.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. Your contract with the Plan says that there is a $100 deductible that applies towards out-of-network medical eye exams and a 40% coinsurance for out-of-network Medicare-covered eye exams. The medical eye exam you asked the Plan to reduce the cost share for falls within the "Vision care" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $100 deductible that applies towards out-of-network medical eye exams and 40% coinsurance for out-of-network Medicare-covered eye exams. This cost sharing is a contractual obligation that had not been met at the time the medical eye exam was received on August 16, 2019.Therefore, we decided that the Plan does not have to reduce the cost share for the medical eye exam provided on August 16, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for breast reconstruction (S2068) provided on August 9, 2019.You asked the Plan to pay for breast reconstruction. You say that this surgery was authorized.The Plan denied your request. The Plan says this procedure was reported with an invalid code.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 S2068 is not supported in the medical record. Specifically, this code has a status indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this information, we decided that Medicare rules for coverage of breast reconstruction have not been met.Therefore, we decided that the Plan does not have to pay for breast reconstruction (S2068) provided on August 9, 2019.