Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approvecontinued skilled nursing facility (SNF) services after March 10, 2020.You asked the Plan to pre-approveSNF care. You say that the requested continuation of SNF care is medically necessary.The Plan denied your request. The Plan says that the enrollee does not meet criteria for the continuation of SNF care.The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before the last covered day. This notice must include a description of the enrollee's right to an appeal.We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or more days before March 10, 2020. The Plan must pay for SNF services until the 100-day SNF care benefit is exhausted or daily skilled care is no longer needed and proper notice is issued.Therefore, we decided that the Plan has to pre-approvecontinued skilled nursing facility (SNF) services after March 10, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care.
You asked the Plan to pre-approve continued SNF care. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee has reached their 100 day benefit limit for this benefit period.
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. The file shows that the enrollee received 100 days of SNF care during the benefit period from July 19, 2019 to January 29, 2020. The Plan has covered 100 days of SNF care. Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approveplacement of intra-socket biological dressing (D7922).You asked the Plan to pre-approveplacement of intra-socket biological dressing. You say that you are in a lot of pain, is unable to chew food and has lost 8 pounds.The Plan denied your request. The Plan says the service is not a covered benefit under Medicare or the plan.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.Therefore, we decided that the Plan does not have to pre-approveplacement of intra-socket biological dressing (D7922).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for moderate sedation services (G0500) provided on September 12, 2019.
You asked the Plan to pay for the moderate sedation services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted did not include documentation to support the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status.
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 G0500 is moderate sedation services provided by the same physician or other qualified health care professional performing a gastrointestinal endoscopic service that sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intra-service time; patient age 5 years or older.
We find that CPT code G0500 is not supported in the record. Specifically, the record does not indicate the presence of an independent trained observer. Based on this information, we decided that Medicare rules for coverage of the moderate sedation services have not been met. Therefore, we decided that the Plan does not have to pay for moderate sedation services (G0500) provided on September 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the facet joint injection provided on October 22, 2019.
You asked the Plan to waive the copayment for the facet joint injection. You say that the injection was done in the doctor's office. You say that the copayment is incorrect. 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 each Medicare-covered visit to an in-network outpatient hospital facility. You have been asked to pay a $400 copayment for the facet joint injection. The facet joint injection falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show that the facet joint injection was billed by the hospital. 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 facet joint injection provided on October 22, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Zilretta.You asked the Plan to pre-approveZilretta. You say that the enrollee had relief for several months after the prior Zilretta injection.The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because Zilretta is not intended for repeat administration.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 Zilretta. Our reviewer says that the enrollee does not meet the Medicare criteria for use of Zilretta. Our physician reviewer found the Food and Drug Administration (FDA) has not approved Zilretta for repeat usage.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Zilretta have not been met.Therefore, we decided that the Plan does not have to pre-approveuse of Zilretta.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe office visit provided on November 22, 2019.You asked the Plan to waive the copayment forthe office visit. You say that you never introduced any issues at the visit. You say that you don't like being charged when the visit was supposed to be free.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 $15 copayment for each Medicare-covered, in-network primary care provider visit.You have been asked to pay a $15 copayment for the office visit. The office visitfalls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show that knee pain was discussed,medicationswererecommendedand a prescription was provided. 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 Plandoes not have to waive the copayment forthe office visit provided on November 22, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing rendered to the enrollee on
April 29, 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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a
physician.
We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation.
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 definitive drug testing rendered to the enrollee on April 29, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary.The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.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 admission to an IRF does not meet criteria. Our physician reviewer found the enrollee was admitted to an acute hospital on 3/4/20 with Pneumonia and Flu. She underwent laparoscopic Cholecystectomy on 3/7/20. As of 3/10/20 physician notes said that she has completed antibiotics, Afebrile and has watery diarrhea. The enrollee had community acquired pneumonia. The notes state that the enrollee is medically stable for discharge. There are no physical therapy or occupational therapy assessments in the records provided. Preadmission screen documents her functional status as requiring moderate assist for bed mobility, transfers, dressing and ambulation for 10 feet with a rolling walker. Bathing with maximum assist and dependent for toileting.Based on review of available records, the enrollee does not meet criteria for coverage for an IRF admission. The enrollee is generally medically stable after Cholecystectomy, with no recent neurological or orthopedic events and there is no evidence of complex medical issues that require monitoring by an inpatient physical medicine and rehab physician three times per week or need for acute rehab nursing care. While she may benefit from an assessment and treatment by physical therapy and occupational therapy, there is no evidence of need for an intensive therapy program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation 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 IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit and does not have to waive the coinsurance for a Medicare Part B drug provided by provider on October 23, 2019.You asked the Plan to waive the copayment fora specialist visit and to waive the coinsurance for a Medicare Part B drug. You say that you met the MOOP amount of $3,400 and should not be responsible for 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 the MOOP amount for 2019 is $3,400. Your contract with the Plan also clearly says that enrollees must pay a $45 copayment per specialist visit. Your contract with the Plan also clearly says that enrollees must pay 20% coinsurance for Medicare Part B prescription drugs. You had a specialist visit and received a Medicare Part B drug on October 23, 2019. The record shows that due to the reprocessing of claims you had only paid $3,350.63 toward the $3,400 MOOP amount. Therefore, you are responsible to pay $44.37, which is less than the $45 copayment amount for the specialist visit. The allowed amount for the Medicare Part B drug is $25 and 20% of that is $5. The total amount you owe is: $49.37. You have been asked to pay the total amount of $49.37 for a specialist visit and a Medicare Part B drug. A specialist visit falls within the physician/practitioner services, including doctor's office visits benefit category. A Medicare Part B drug falls within the Medicare Part B prescription drugs 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 fora specialist visit and does not have to waive the coinsurance for a Medicare Part B drug provided by provider on October 23, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for spinal x-rays (72100 and 72040) provided on November 6, 2019 through November 8, 2019.You asked the Planto pay for the spinal x-rays. You say that the x-rays and consultation were important in order to receive effective treatment. The Plan denied your request. The Plan says the only thing covered, when performed by a chiropractor is manipulation of the spine.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 for spinal x-rays (72100 and 72040) provided on November 6, 2019 through November 8, 2019. Your complaint about being provided with incorrect information is 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
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided to the enrollee on August 11, 2019.
You asked the Plan to waive the copayment for the ambulance transport. You say that the claim needed to be considered in-network. The Plan denied your request. The Plan says that 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $230 copayment for each one-way Medicare-covered ground trip. The enrollee has been asked to pay a $230 copayment for the ambulance transport. The ambulance transport falls within the one-way Medicare-covered ground trip benefit category. 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 the ambulance transport provided to the enrollee on August 11, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe CT scan provided on November 19, 2019.You asked the Plan to waive the copayment forthe CT scan. You say that you paid the $90 copayment. You say that you weren'tgiven information on the extra cost.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 $225 copayment for each Medicare-covered advanced imaging service from an in-network provider.You have been asked to pay $107.27, which is less than the standard $225 copayment for the CT scan. The CT scan 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 forthe CT scan provided on November 19, 2019
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Xolair injections.
You asked the Plan to pre-approve Xolair injections. You say that the enrollee has tried everything else. The Plan denied your request. The Plan says that this is not necessary due to discrepancies in the enrollee's medication history.
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 Xolair injections. Our reviewer says that Xolair is medically appropriate for the treatment of the enrollee's chronic idiopathic urticaria. Our physician reviewer found the enrollee has had ongoing symptoms for 9 months despite treatment with multiple antihistamines and an antileukotriene in addition to prednisone. This treatment is steroid sparing and has been proven to be effective for such patients. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Xolair injections have been met. Therefore, we decided that the Plan has to pre-approve Xolair injections.
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 waive the copayment for ophthalmic biometry provided by provider on July 11, 2019.You asked the Plan to waive the copayment for ophthalmic biometry. You say that this was a follow-up visit and 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 $35 copayment per specialist visit. You received ophthalmic biometry on July 11, 2019. Follow-up visits are subject to cost-sharing charges. Therefore, you are responsible to pay the allowed amount of $30.69, which is less than the $35 copayment. You have been asked to $30.69 for ophthalmic biometry. Ophthalmic biometry falls within the physician/practitioner services, including doctor's office visits 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 forophthalmic biometry provided by provider on July 11, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the retainer crowns (D6740 x 4) and the pontic (D6245) provided on September 18, 2019.
You asked the Plan to reimburse you for the dental services. You say that you fell and broke your dental bridge beyond repair. You say that this claim should have been submitted to the medical department, not the dental department. You also say that it was a medical episode that created these dental injuries. The Plan denied your request. The Plan says retainer crowns and pontics are not listed as covered services.
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 services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Though the Plan offers a dental benefit in excess of Medicare coverage, retainer crowns and pontic are not among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for the retainer crowns (D6740 x 4) and the pontic (D6245) provided on September 18, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services received on November 8, 2019.
You asked the Plan to pay for the services. You say that it is your understanding that lab work for a physical is
covered in full. The Plan denied your request. The Plan says the copayment was applied appropriately
according to your benefits and the services rendered.
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 lab services.
You have been asked to pay a $10 copayment for the services. The services fall within the lab 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 pay for lab services received on November 8, 2019.