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

We decided that the Plan does not have to pay for the 3D photographic image (D0351), and bone graft at time of implant placement (D6104), or pay more for the problem focused limited oral evaluation (D0140), panoramic x-ray (D0330), and extraction (D7140) provided on September 24, 2020 by an OON provider.
You asked the Plan to pay for the 3D photographic image, and bone graft at time of implant placement, and to pay more for the problem focused limited oral evaluation, panoramic x-ray, and extraction. You say that you feel that you should not be held responsible for these charges. The Plan denied your request. The Plan says the 3D photographic image and bone graft at time of implant placement are not covered services. The Plan also says that the claim was paid correctly up to the annual maximum allowable for an OON provider.
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 3D photographic image and bone graft at time of implant placement are not among those covered under this benefit. You are also responsible for the difference between the billed amount and allowed amount for dental services received OON. Therefore, we decided that the Plan does not have to pay for the 3D photographic image (D0351), and bone graft at time of implant placement (D6104), or pay more for the problem focused limited oral evaluation (D0140), panoramic x-ray (D0330), and extraction (D7140) provided on September 24, 2020 by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gel-One.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the step therapy requirement is not met.
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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found you have knee osteoarthritis. You have not tried and failed the Plan's required drugs, Durolane, Euflexxa, Gelsyn, or Supartz. The records do not show that the required drugs would be less effective or harmful; therefore, the Gel-One is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Gel-One.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MyoPro Motion G Orthotic device (CPT code L8702), for the enrollee.
You asked the Plan to pre-approve the device. You say that the enrollee will not be able to use their arm again without external power, and there are no other therapeutic alternatives apart from the MyoPro capable of restoring the enrollee's arm function. The Plan denied your request. The Plan says peer reviewed literature considers the use of robotic therapy for upper and lower extremity stroke rehabilitation investigational in nature and does not support its use since there is no long-term outcome data or continuation rate data at this time.
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 items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the MyoPro orthosis is considered experimental, investigational and unproven when used to help restore function to arms and hands paralyzed or weakened by cerebrovascular accident (CVA) stroke, brachial plexus injury, cerebral palsy or any other neurological or neuromuscular disease or injury. There is insufficient literature in the peer reviewed publications to assess safety, efficacy, long term outcomes or patient management associated with the use of the MyoPro Orthosis for upper extremity paralysis/paresis. There is a
paucity of literature in the peer reviewed publications to assess safety, efficacy, long term outcomes or patient management associated with the use of the MyoPro Orthosis for upper extremity paralysis/paresis. At the current time the literature consists prospective comparative studies, prospective uncontrolled studies and case reports. These studies have a small number of participants and short-term follow-up. Additional studies with larger numbers of participants are needed that show consistent improvements in relevant outcome measures. The review indicates that the items/services at issue in this case are not medically reasonable or 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the MyoPro Motion G Orthotic device (CPT code L8702), for the enrollee.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urgent care visit provided March 18, 2021.

You asked the Plan to waive the copayment for the urgent care visit. You say that your copay should be $35 not $70. You had a previous visit to this urgent care and paid only $35 copay. The Plan denied your request. The Plan says the claim was processed with the correct copayment applied per the Evidence of Coverage.

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 $35 copay for Medicare covered urgently needed care visits. 

You have been asked to pay $35 copay for the urgent care visit. The urgent care visit falls within the Urgently needed services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the urgent care visit provided March 18, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from March 7, 2021 to March 10, 2021.

You asked the Plan to waive the copayment for the inpatient services. You say that these services were necessary, and you do not feel it is fair that you need to pay two separate copayments for the two separate hospital admissions. The Plan denied your request. The Plan says the request for the second hospital admission is being addressed in a separate case, but the copayment for the visit from March 7, 2021, to March 10, 2021, was 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 $325 copayment for each of the first 6 days of an inpatient hospital admission. 

You have been asked to pay a $975 copayment for the three-day inpatient hospital admission ($325 x 3 = $975). 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 hospital care provided from March 7, 2021 to March 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for fitness equipment purchased on November 29, 2020.

You asked the Plan to pay for fitness equipment. You say that you called before purchasing the device and was advised that you can submit for reimbursement. The Plan denied your request. The Plan says the Fitbit that was purchased is not a covered item for the 2020 Wellness Allowance benefit.

The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan contract for 2020 states that the Plan can pay up to $300 per calendar year toward your cost of a membership in a qualified health club or fitness facility, covered instructional fitness classes, participation in wellness programs, memory fitness activities, acupuncture and/or nutritional counseling. As of October 1, 2020, and until December 31, 2020, this benefit may also be used toward the purchase of exercise equipment that you can use at home such as treadmills, exercise bikes, ellipticals, free weights, resistance bands, weight stations, jump robes, yoga mats and subscription services to online classes. 

The Plan's rules for coverage of gym benefits have not been met because the purchased Fitbit is not a covered item under your Wellness Allowance benefit. Therefore, we decided that the Plan does not have to pay for fitness equipment purchased on November 29, 2020.
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 inpatient rehabilitation is medically necessary for this enrollee. The Plan denied your request. The Plan says the criteria for an IRF are not met. The necessary care can be provided in another setting.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The
enrollee does require physical and occupational therapy, but there is no documented need for an intensive rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Medically necessary services can be provided in a different level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
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 you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not medically necessary. Our physician reviewer found you were admitted to the hospital for surgical repair of a hip fracture after a fall. You are now medically stable with no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. You require further therapy but do not need an intensive therapy program in an IRF. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on July 9, 2020.

You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.

The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.

We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on July 9, 2020.
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for weakness, rhabdomyolysis and pneumonia. The enrollee's medical conditions are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The patient does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for the TENS unit and supplies, vasopneumatic device and vitamin injections provided on August 5, 2020.
You asked the Plan to pay for the TENS unit, vasopneumatic device and vitamin injections.. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the member does not meet Medicare criteria for coverage of the billed services.
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 TENS unit, vasopneumatic device and vitamin injections. Our reviewer says that for a pneumatic device, the member was not noted to have received treatment/therapy with this device for edema. The member's physical exam did not indicate the presence of edema. While there is a statement in the chart note that this service was done to reduce edema, However, in the absence of a documented symptom such a treatment cannot be determined to be appropriate. For TENS, the member was noted to have low back pain (an indication fro which Medicare does not cover TENS outside of a clinical trial) and diabetic peripheral neuropathy (DPN). There is not sufficient literature to support the use of TENS in DPN. In as much this service would also not have been medically necessary. Our physician reviewer found the use of "nutraceuticals" for the management of pain is not readily consistent with the generally accepted standards of practice/care. There is not a body of credible literature readily available to support such a course of treatment/therapy. In as much this service would have been better classified as being experimental and therefore would not have met Medicare criteria for coverage. 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 TENS unit, vasopneumatic device and vitamin injections. have not been met. Therefore, we decided that the Plan does not have to pay for the TENS unit and supplies, vasopneumatic device and vitamin injections provided on August 5, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital services provided from July 14, 2020, through
July 16, 2020.

You asked the Plan to pay for the hospital services. The Plan denied your request. The Plan says out of network
services 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
hospital 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 hospital services provided from July 14, 2020, through
July 16, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested routine transportation trip.
You asked the Plan to pre-approve the requested routine transportation trip. You say that you need this routine transportation to receive your medical services. The Plan denied your request. The Plan says the Plan does not allow for routine transportation trips greater than 50 miles.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers routine transportation when each one-way trip does not exceed 50 miles of driving distance.
We looked at your request, the records in the case file, and the rules. In this case, the requested trip has a distance that exceeds 50 miles. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve the requested routine transportation trip.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for routine foot care you received on April 8, 2021.

You asked the Plan to pay for the foot care. The Plan denied your request. The Plan says this is not a covered benefit.

The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or feet or have fungal nails. 

The records do not show that any of these conditions are present. The services you are asking the Plan to pay for are routine foot care services. Based on this information, we decided that Medicare rules for coverage of the foot care have not been met. Therefore, we decided that the Plan does not have to pay for routine foot care you received on April 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for polycarbonate lenses (V2784) and spherocylinder lenses (V2203) provided on February 24, 2021.
You asked the Plan to pay for polycarbonate lenses and spherocylinder lenses. You say that you do not understand how you exhausted your benefits. You also say that the last time you received these services were October 2019 and you are confused with the denials. The Plan denied your request. The Plan says you met your allowed benefit with this claim.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan contract says you have a $70 allowance every 24 months to use towards eyeglasses. We looked at the file and the Plan's rules. The records show you exhausted your $70 maximum allowed benefit on February 24, 2021. The records also show that you purchased frames at an allowed amount of $55 and a polycarbonate lens of the right eye, which partially covered the remaining allowed benefit of $15. You received the total allowed amount of $70. The remaining amount for the right polycarbonate lens as well as the left polycarbonate lens and the spherocylinder lenses are therefore not covered and become your responsibility. Based on this information, we decided that the Plan's rules for coverage of a polycarbonate lens and a spherocylinder lens have not been met. Therefore, we decided that the Plan does not have to pay for polycarbonate lenses (V2784) and spherocylinder lenses (V2203) provided on February 24, 2021.