Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional Personal Care Assistant hours (T1019).
You asked the Plan to pre-approve the additional Personal Care Assistant services. You say that the Personal Care Assistant services are medically necessary as the member needs assistance moving around the house and with grooming, bathing, medication reminders, light meal prep and companionship in case of emergency. The Plan denied your request. The Plan says Medicare considers these services custodial in nature and Medicare does not cover custodial services.
The Plan must follow Medicare rules. Medicare rules say that custodial care is not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the additional Personal Care Assistant services have not been met. Specifically, the Personal Care Assistant services are considered custodial services. Medicare does not cover custodial services. Therefore, we decided that the Plan does not have to pre-approve additional Personal Care Assistant hours (T1019).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested admission to a LTACH is not medically necessary. Our physician reviewer found the enrollee was admitted to acute care on 12/21/19 for treatment of cardiac arrest. The enrollee was found unresponsive without a pulse, intubated on admission and started on IV Levophed. On 1/7/2020 a tracheostomy and PEG tube were placed. On 1/25/2020 the enrollee is breathing comfortably over PRVC mode, tolerating CPAP for 8 hours. Midazolam infusion is ongoing. Per MD progress note, the enrollee is without brainstem reflexes and requires increasing pressor support (continues on IV Levophed and IV dobutamine infusions). There is no documentation provided necessitating admission to a LTACH. The enrollee's current needs are being met in the acute setting. The LTACH would add no additional services. The review has determined that the enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve clobetasol for the enrollee.
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 self-administered drugs are not covered.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve clobetasol for the enrollee.
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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve routine transportation services.
You asked the Plan to pre-approve the routine transportation services. You say that you only have one artery in your heart and your doctor has recommended heart therapy. You say that your health will deteriorate if you do not have transportation to and from your appointments at the facility. You say that treatment is for a total of 7 weeks and visits are 5 times a week. You say that you do not have family that can take time off of work or friends that still drive. The Plan denied your request. The Plan says routine transportation is not covered by the enrollee's benefit plan.
The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. The Plan follows the same rule. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Medicare rules for coverage of the routine transportation services have not been met. Therefore, we decided that the Plan does not have to pre-approve routine transportation services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve placement of a Superion interspinous spacer.
You asked the Plan to pre-approve the Superion spacer. You say that this surgery would be helpful and should
not be considered experimental. The Plan denied your request. The Plan says this treatment has not been
proven effective.
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 Superion spacer. Our reviewer says
that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee has lumbar stenosis. The use of this spacer remains experimental. More
research is needed to show safety and efficacy.
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 Superion spacer have not been met. Therefore, we decided that the Plan
does not have to pre-approve placement of a Superion interspinous spacer.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a routine vision exam.You asked the Plan to pre-approvea routine vision exam. You say that this was previously covered and that you cannot afford to pay for this service.The Plan denied your request. The Plan says that this is not covered by Medicare or your plan.The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. The services you asked the Plan to pre-approve are considered routine vision services or eyewear.Therefore, we decided that the Plan does not have to pre-approvea routine vision exam.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a grab bar.You asked the Plan to pre-approve a grab bar. You say that the requested bath wall rails are for your safety concerns and not for hygiene purposes.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan covers all items that Medicare covers. Medicare rules state that grab bars are not covered because they are not primarily medical in nature. While a grab bar may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.Therefore, we decided that the Plan does not have to pre-approvea grab bar.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve2 porcelain crowns for teeth # 22 and 30.You asked the Plan to pre-approvethe dental services. The Plan denied your request. The Plan says the porcelain crowns for teeth # 22 and 30 are not medically necessary.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 the dental services 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 dental services. Our reviewer says that the crowns for teeth # 22 and 30 does not meet the criteria for coverage. Our physician reviewer found tooth #22 appears to have a crown in place as an abutment for a bridge and the prognosis for the retention for tooth #30 ispoor due to the severe periodontal disease.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 dental services have not been met.Therefore, we decided that the Plan does not have to pre-approve2 porcelain crowns for teeth # 22 and 30.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Glucocard blood glucose monitor and test strips for the enrollee.
You asked the Plan to pre-approve these services. You say that this is medically necessary. The Plan denied your request. The Plan says that the enrollee can use the preferred products.
The Plan must follow Medicare rules. Medicare rules say that plans may limit enrollees to preferred providers. The items at issue are a blood glucose monitor and test strips. Glucocard is not a preferred provider with the Plan for diabetic supplies. ACCU-CHEK and OneTouch are the preferred providers. Therefore, we decided that the Plan does not have to pre-approve a Glucocard blood glucose monitor and test strips for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean interim maxillary partial denture (D5820).You asked the Plan to pre-approvean interim maxillary partial denture. You say that when the central teeth are extracted, the pockets on teeth # 7 and 10 will reduce.The Plan denied your request. The Plan says interim partial denture is not listed as a covered service.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 item is not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvean interim maxillary partial denture (D5820).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea power operated vehicle (POV). You asked the Plan to pre-approvea scooter. You say that you are isolated and you need a POV to allow independent access to your community including stores, coffee shop and supermarket.The Plan denied your request. The Plan says the assessmentshows your home is cluttered, lacking space to operate a scooter, and you have no place to safely park the scooter. The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The file shows that you cannot safely operate the PMD being requested. The assessment shows your home does not have adequate access for a PMD and Medicare does not cover PMDs for use only outside the home. This means that Medicare rules for coverage of a PMD have not been met.Therefore, we decided that the Plan does not have to pre-approvea power operated vehicle (POV)
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Synvisc injection (J7325).
You asked the Plan to pre-approve a Synvisc injection (J7325). You say that the requested Synvisc injection is medically necessary. The Plan denied your request. The Plan says the requested Synvisc injection does not meet criteria.
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 a Synvisc injection (J7325). Our reviewer says that the requested Synvisc injection does not meet criteria. Our physician reviewer found the enrollee is with osteoarthritis of the knee. Based on the records provided, the documentation does not support the need for a Synvisc injection. There is no functional deficit documented in the records. More documentation is needed. At this time, the enrollee does not meet criteria for the requested Synvisc injection. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Synvisc injection (J7325) have not been met. Therefore, we decided that the Plan does not have to pre-approve a Synvisc injection (J7325).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvedurable medical equipment (DME).You asked the Plan to pre-approvethe DME. You say that the enrollee is facility-bound and has limitations in transportation to travel to an in-network DME provider. You say your company has a mobile delivery van that is willing to travel to the enrollee's facility to provide the itemsthat the physician ordered.The Plan denied your request. The Plan says the enrollee must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.Medicare rules say that plans can require enrollees to getcare from network providers. The contract with the Plan says that the Plan has to pre-approve 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 DME itemsat issue in this appeal. We found no exception that would require the Plan to pre-approve the requested items.Therefore, we decided that the Plan does not have to pre-approvethe durable medical equipment (DME).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Computed Tomography (CT) quantitative calcium scoring.You asked the Plan to pre-approve  quantitative calcium scoring. You say that you are appealing with medical records.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this test is not covered by Medicare.The Plan must follow Medicare rules. Medicare rules say that CT with quantitative calcium scoring is not covered by Medicare. We looked at the file and Medicare rules. The requested test is not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of quantitative calcium scoring have not been met.Therefore, we decided that the Plan does not have to pre-approveComputed Tomography (CT) quantitative calcium scoring.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650) provided to the enrollee on September 20, 2019.You asked the Plan to pay for the orthosis. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation submitted did not include an itemized shipping/billing invoice from the billing provider to indicate the specific supplies.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case.  The submitted packing slip shows the provider as Mediquipt, billed to Palm Beach Medical Supply; therefore the billed supply code cannot be verified.Therefore, we decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650) provided to the enrollee on September 20, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for SNF care provided to the enrollee from May 9, 2019 through May 20, 2019.You asked the Plan to pay for SNF care. You say that the stay was medically necessary.The Plan denied your request. The Plan says the stay is not medically necessary.The Plan must follow Medicare rules. The rules say that 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 pay for SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on available records, the patient does not meet criteria for coverage of SNF during the dates at issue. The records do not support that the enrollee was participating in daily physical therapy (PT) and occupational therapy (OT). There were no noted daily skilled complex nursing needs. While she may have benefited from continuing PT and OT, the records do not support the need for daily therapy and there is no documentation of daily skilled nursing.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met.Therefore, we decided that the Plan does not have to pay forSNF care provided to the enrollee from May 9, 2019 through May 20, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveTrulicity.You asked the Plan to pre-approveTrulicity. The Plan denied your request. The Plan says this drug is not covered under Part B.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approveTrulicity
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fortest strips (A4253), lancets (A4259), calibrator solution (A4256), and a battery (A4235) provided from August 20, 2019 to November 8, 2019.You asked the Plan to pay fortest strips, lancets, calibrator solution, and a battery. You say that these items should be covered.The Plan denied your request. The Plan says the delivery ticket submitted did not include the carrier's tracking number, nor did the proof of delivery include an order number or details to corroborate the delivery ticket.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the physicianorder and proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. Specifically, the delivery ticket and the proof of delivery did not corroborate one another in regards to an order number and carrier.Therefore, we decided that the Plan does not have to pay fortest strips (A4253), lancets (A4259), calibrator solution (A4256), and a battery (A4235) provided from August 20, 2019 to November 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have topay for test strips (A4253), lancets (A4259), calibrator solution (A4256), and a battery (A4235) provided from August 13, 2019 to November 1, 2019.You asked the Plan to pay fortest strips, lancets, calibrator solution, and a battery. You say that these items should be covered.The Plan denied your request. The Plan says the delivery ticket submitted did not include the carrier's tracking number, nor did the proof of delivery include an order number or details to corroborate the delivery ticket.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. Specifically, the delivery ticket and the proof of delivery did not corroborate one another in regards to an order number and carrier.Therefore, we decided that the Plan does not have to pay fortest strips (A4253), lancets (A4259), calibrator solution (A4256), and a battery (A4235) provided from August 13, 2019 to November 1, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe diabetic shoe inserts provided on September 9, 2019.You asked the Plan to waive the coinsurance forthe diabetic shoe inserts. You say that you should not be billed for the diabetic inserts. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for Medicare-covered therapeutic shoes and inserts. You have beenasked to pay $48.19 which is 20% of the allowed amount for the diabetic shoe inserts. The allowed amount is $240.93. ($240.93 x 20% = $48.19). The diabetic shoe inserts fall within the "Diabetes self-management training, diabetic 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 coinsurance forthe diabetic shoe inserts provided on September 9, 2019.Your complaint about the provider committing fraud 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 pay for the ambulance services.You asked the Plan to pay forthe ambulance services. You say that you had a legitimate medical issue and should have been transported to the hospital. You say that you are hard of hearing and without your hearing aids, you could not fully comprehend what the responding paramedics were saying. You believe that you could not make an informed decision regarding what was necessary for your health.The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on April 23, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have topay forthe ambulance services.