Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulatory infusion pump and supplies provided from April 8, 2019 to September 9, 2019.
You asked the Plan to pay for the ambulatory infusion pump and supplies. You say that the Plan should pay this claim. The Plan denied your request. The Plan says the ambulatory infusion pump and supplies are inclusive under services approved and paid at the facility and you should bill the facility.
The Plan must follow Medicare rules. Medicare rules say payment for the administration of the drug will also include payment for equipment used in furnishing the service. In this case, the CPT Code Manual definition of code A4222 is infusion supplies and E0781 is Ambulatory infusion pump. Medicare's payment for the supplies billed to the MAC includes payment for the equipment and they are not separately payable. Based on this information, we decided that Medicare rules for coverage of the ambulatory infusion pump and supplies have not been met. Therefore, we decided that the Plan does not have to pay separately for the ambulatory infusion pump and supplies provided from April 8, 2019 to September 9, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you forthe osseous surgery for 4 or more teeth per quadrant (D4260 x 4), the osseous surgery for 1 to 3 teeth per quadrant (D4261 x 4), and the periodontal scaling and root planing (D4341 x 3) provided from August 8, 2019 to October 24, 2019.You asked the Plan to reimburse you forthe dental services. You say that the services you received should be covered under your medical benefits.The Plan denied your request. The Plan says the services that you received are dental in nature. The Plan says that the dental services are not covered under your medical benefit. The Plan also says that the maximum allowance of $260 for comprehensive dental services has been exhausted.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 $260 benefit allowance for comprehensive dental services has been exhausted.Date of ServiceReimbursement Amount3/25/2019$813/25/2019$307/29/2019$348/8/2019$115TOTAL:$260 Therefore, we decided that the Plan does not have to reimburse you forthe osseous surgery for 4 or more teeth per quadrant (D4260 x 4), the osseous surgery for 1 to 3 teeth per quadrant (D4261 x 4), and the periodontal scaling and root planing (D4341 x 3) provided from August 8, 2019 to October 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code E1399.
You asked the Plan to pre-approve the compression stockings. You say that the enrollee requires the stockings for edema. The Plan denied your request. The Plan says gradient compression stockings E1399 are non-covered when there is no qualifying wound.
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code E1399 are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound. The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you do not have a medical condition for which compression stockings can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code E1399.
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 SNF admission. You say that the enrollee would benefit from SNF care due to his low functional status.The Plan denied your request. The Plan says the enrollee does not require daily skilled nursing services and the enrollee would be safe for discharge with 24-hour non-skilled supervision and intermittent home health PT.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 SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted on 4/3/2020 due to weakness and hypotension, found to have bradycardia with anemia due to suspected GI bleed. He had an EGD, showing no evidence of active bleed. The enrollee is supervised for functional transfers and mobility using a walker. Hemodynamics are stable. Co-morbid conditions include congestive heart failure and sleep apnea.The enrollee is now mostly supervised for care. He has no complex wound care needs, or IV medication requirements. There are no nursing or therapy needs that are skilled, and warranting a SNF as opposed to a lesser level of care (including home health care services). His vital signs are stable and SNF is 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 SNF 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe Riboflavin solution provided on November 20, 2019.You asked the Plan to waive the copayment forthe Riboflavin solution. You say that you were pre-approved for the procedure including all fees except the copayment. You say that the Plan should pay what they agreed to pay.The Plan denied your request. The Plan says the coinsurance 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 mustpay 20% for Medicare-covered Part B chemotherapy drugs and other Part B drugs. You have been asked to pay $763.20, which is 20% of the allowed amount for the Riboflavin solution. The allowed amount is $3,816 (20% x $3,816 = $763.20). The Riboflavin solution 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 forthe Riboflavin solution provided on November 20, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from November 5, 2019 through November 17, 2019. You asked the Plan to waive the copayment for the inpatient stay. You say that if you were not discharged previously, you would have continued coverage without a second copayment. You say that you should not be charged. 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 $175 copayment per day, for days 1 to 5 and a $0 copayment per day, for days 6 to 90 for each in-network inpatient hospital stay. Your contract with the Plan clearly says that your inpatient cost share will begin on day one each time you are admitted or transferred to a specific facility type. You have been asked to pay $738.77, which is less than the standard $175 copayment per day for the inpatient stay because you met your maximum out-of-pocket. ($175/day x first 5 days = $875). The inpatient stay falls within the "Inpatient hospital care" benefit category. The records show that this was separate inpatient admission. 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 inpatient stay provided from November 5, 2019 through November 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an insulin pump.
You asked the Plan to pre-approve the pump. You say that this is medically necessary. The Plan denied your
request. The Plan says this is not covered for your condition.
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 pump. Our reviewer says that the
requested pump is not considered medically reasonable and necessary in this case. Our physician reviewer
found the he enrollee is noted to be a type II diabetic, who takes both oral medication and set dose insulin to
treat her diabetes. A c-peptide test completed on 10/8/2019 was less than 110% of the lab's lower range and
associated with a fasting glucose of less than 225. B cell antibody testing is not noted. While the enrollee meets
c-peptide criteria for insulin pump coverage, the fact that she does not use an insulin sliding scale does not
meet criteria. The requested insulin pump is not shown to be medically necessary or reasonable. For the
specific coverage criteria - the enrollee meets A, but not B, C, or D.
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 pump have not been met. Therefore, we decided that the Plan does not have
to pre-approve an insulin pump.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy rendered from August 8, 2019 to August 15, 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 the services are not covered. The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The
Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies. We looked at the file and Medicare and the Plan's rules. Based on this information, we decided that Medicare and the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy rendered from August 8, 2019 to August 15, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the wheelchair transit option.You asked the Plan to pay for the wheelchair transit option. You say that the enrollee needs to be secured safely in your vehicle when transporting.The Plan denied your request. The Plan says this feature is not covered by Medicare or the Plan.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.This item is not covered by Medicare. Therefore, we decided that the Plan does not have to pay for the wheelchair transit option.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (Denosumab).
You asked the Plan to pre-approve Prolia. You say that your doctor believes Prolia is more appropriate than
zoledronic acid. The Plan denied your request. The Plan says you have not tried zoledronic acid.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.
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 Prolia. Our reviewer says that the
criteria for coverage of Prolia have not been met. Our physician reviewer found the Plan requires a trial of one
oral bisphosphonate and (Reclast) zoledronic acid before they will approve the requested drug. There is no
documentation of the trial and failure of Zoledronic acid. The documentation does not support that Zoledronic
acid would likely be less effective or would likely have adverse effects for you in this case.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to
pre-approve Prolia (Denosumab).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the insertion of peripherally inserted central venous catheter (PICC) services coded 36573 provided on November 7, 2019.
You asked the Plan to pay for the insertion of peripherally inserted central venous catheter (PICC). 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 supported by the documentation.
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 36573 is Insertion of peripherally inserted central venous catheter (PICC), without subcutaneous port or pump, including all imaging guidance, image documentation, and all associated radiological supervision and interpretation required to perform the insertion; age 5 years or older. We find that CPT code 36573 is not supported in the medical record. Specifically, the documentation supports that one unit of this code was provided. One unit of this code was already been approved/paid by the plan. Therefore, any other units of this code are not supported by the documentation. Based on this information, we decided that Medicare rules for coverage of the insertion of peripherally inserted central venous catheter (PICC) have not been met. Therefore, we decided that the Plan does not have to pay for the insertion of peripherally inserted central venous catheter (PICC) services coded 36573 provided on November 7, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy rendered from December 25, 2019 to December 31, 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 the services are not covered.
The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies. We looked at the file and Medicare and the Plan's rules. Based on this information, we decided that Medicare and the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy rendered from December 25, 2019 to December 31, 2019.
Benefits for these services 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis (D1110) provided on October 30, 2019 by an
out of network provider.
You asked the Plan to pay for the dental service. You say that you are on Social Security and Disability. You
say that you cannot afford to pay this bill. The Plan denied your request. The Plan says the provider in this case
is not a network provider. The Plan also says care rendered by a provider that is not part of our supplemental
dental network is not covered.
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, dental services received out of network
are not covered. The Evidence of Coverage clearly states that care rendered by a provider that is not part of our
supplemental dental network is not covered. Therefore, we decided that the Plan does not have to pay for the
prophylaxis (D1110) provided on October 30, 2019 by an out of network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the Knee (73721).
You asked the Plan to pre-approve the MRI of the knee. You say that the MRI is medically necessary. The Plan denied your request. The Plan says rules for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 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 the MRI of the knee. Our reviewer says that the MRI is not medically necessary. Our physician reviewer found documentation does not include a detailed history of knee pain, physical examination of the knee, a discussion of conservative therapy, or a differential diagnosis. 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 MRI of the knee have not been met. Therefore, we decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the Knee (73721).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 77065 provided on October 16, 2019.You asked the Plan to pay for CPT code 77065. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services are not covered.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 77065 is Diagnostic mammography, including computer-aided detection (CAD) when performed; unilateral.We find that CPT code 77065 is not supported in the medical record. Specifically, the submitted documentation indicted that the mammography was performed to verify the proper placement of localization device which is not diagnostic. Based on this information, we decided that Medicare rules for coverage of CPT code 77065 have not been met.Therefore, we decided that the Plan does not have to pay for CPT code 77065 provided on October 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network provider on June 21, 2019.
You asked the Plan to pay for the services. You say that you didn't know this provider was no longer in-network. The Plan denied your request. The Plan says the 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 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 you by an out-of-network provider on June 21, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on December 20, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 19350 is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 19350 is nipple/areola reconstruction. We find that CPT code 19350 is not supported in the medical record. Specifically, the operative report does not include documentation of a nipple/areola reconstruction. 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 surgical services rendered on December 20, 2019.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the crown and core buildup, including any pins when required, provided on October 31, 2019.You asked the Plan to pay for the crown and core buildup. You say that the diagnosis is consistent with a large amalgam filling with recurrent decay under. You also say that due to the symptoms and visual findings after the decay was removed and fracture was confirmed there was not enough sound tooth structure left to support a direct restoration, resulting in the need of a buildup and crown.The Plan denied your request. The Plan says that the review does not show extensive decay or fracture of tooth supporting need for crown. The Plan also says that benefits are allowed for buildup only if it is essential for crown retention as stated in the Plan guidelines.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 crown and core buildup by the provider. The provider is a contract provider. The file does not show that the plan provided notice that the crown and core buildup would not be covered. Under Medicare rules, this means the crown and core buildup are considered approved by the plan.Therefore, we decided that the Plan has to pay for the crown and core buildup, including any pins when required, provided on October 31, 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 the new information. This does not happen often. If we decide to open the case again, we will send you a letter.