Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient mental health care provided to the enrollee from March 8, 2019 through March 12, 2019. 
 
You asked the Plan to pay for inpatient mental health 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 inpatient psychiatric services may be covered if the patient requires active treatment.  
 
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 inpatient mental health care. Our physician reviewer found this enrollee did not appear to require inpatient mental health treatment as the enrollee was not a danger to themselves or others and was cooperative with care without any aggressive behaviors. It did not appear that active treatment was taking place. It did not appear that the services were reasonably expected to improve the patient's condition or for the purpose of diagnosis. This patient was treated under an individualized treatment found in the record. It did appear that the records were supervised and evaluated by a physician. Based upon review the records provided for the admission of this patient does not meet criteria for acute inpatient mental health treatment as the enrollee was not shown to be a danger to themselves or others, auditory or visual hallucinations. The enrollee is noted to be cooperative and compliant with treatment while not showing any aggressive behaviors or any behaviors on withdrawal causing an acute threat to safety. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient mental health care have not been met. Therefore, we decided that the Plan does not have to pay for inpatient mental health care provided to the enrollee from March 8, 2019 through March 12, 2019.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to reduce the copayment for the office visit. We decided that the Plan does not
have to waive the coinsurance for the Part B injection.
You asked the Plan to waive the cost share for the services. You say that you feel you should not be responsible
for this cost share amount and you would like the Plan to reconsider your request. The Plan says that you
received a Part B injection and specialist visit on the date of service at issue in this appeal. The Plan says that
the correct cost share has applied per your contract with the Plan.
We decided that the Plan has to reduce the copayment for the office visit.
The Plan follows Medicare rules. The rules say a Plan must disclose to its enrollees in clear, accurate terms all
cost-sharing information (such as copayments, deductibles, and coinsurances). Your contract with the Plan
clearly says that you must pay a $10 copayment for vision services. Therefore, we decided that the Plan has to
reduce the copayment for the office visit.
We also decided that the Plan does not have to waive the coinsurance for the Part B injection.
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 20%
coinsurance for Medicare Part B prescription drugs. Therefore, we decided that the Plan does not have to waive
the coinsurance for the Part B injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device (HFCWOD).
You asked the Plan to pre-approve a HFCWOD. You say that this is medically necessary. The Plan denied your request. The Plan says that you do not have a qualifying diagnosis.
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases. 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 HFCWOD. Our reviewer says that a HFCWOD is not medically reasonable and necessary in this case. You do not have cystic fibrosis, bronchiectasis, or one of the neuromuscular diseases for which a high frequency chest wall oscillation device may be covered. You do not presently use a mechanical in-exsufflation device (E0482). Chronic bronchitis and chronic obstructive pulmonary disease (COPD) in the absence of a confirmed diagnosis of bronchiectasis do not meet this criterion. The records do not show well-documented failure of standard treatments to adequately mobilize retained secretions. Our physician reviewer found that your condition does not meet Medicare criteria for HFCWOD. 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 HFCWOD have not been met. Therefore, we decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device (HFCWOD).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for continuous passive motion exercise device
for use on knee only (E0935) provided from February 21, 2020 through March 12, 2020.
You asked the Plan to waive the coinsurance for the DME. You say that you should not have to pay the
coinsurance since you were told that it was free for the first twenty-one (21) days. The Plan denied your
request. The Plan says the claim was processed accordingly with your 2020 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance).
Review of the file show that you received a continuous passive motion exercise device for use on knee only
(E0935) provided from February 21, 2020 through March 12, 2020. You are asked to pay 20% coinsurance for
the DME. 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 for continuous passive motion exercise device for
use on knee only (E0935) provided from February 21, 2020 through March 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve deep sedation/general anesthesia first 15 minutes (D9222) and deep sedation/general anesthesia each additional 15 minutes (D9223). You asked the Plan to pre-approve the dental services. You say that please add on sedation/anesthesia now because they had missed it on the 1st request. The Plan denied your request. The Plan says this service is not covered under the plan benefits. 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-approve deep sedation/general anesthesia first 15 minutes (D9222) and deep sedation/general anesthesia each additional 15 minutes (D9223).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay fora bone scan (77080) provided February 20, 2020.You asked the Plan to pay forthe bone scan. You say that the services were medically necessary.The Plan denied your request. The Plan says the claim is a duplicate.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT code 77080 is not supported in the medical record. Specifically, the record shows payment was already made for this service under claim number 820200650481916. Based on this information, we decided that Medicare rules for coverage of the bone scan have not been met.Therefore, we decided that the Plan does not have to pay fora bone scan(77080) provided February 20, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide additional non-emergency medical transportation.You asked the Plan to provide additional non-emergency medical transportation. You say that the enrollee needs to come to your office several times a week and is unable to drive.The Plan denied your request. The Plan says there are not additional transportation benefits available once it is exhausted.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 a maximum of 20 one-way trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation.Therefore, we decided that the Plan does not have to provide additional non-emergency medical transportation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids purchased on May 8, 2017 from a nonparticipating
provider.
You asked the Plan to pay for the hearing aids. You say that there was no vendor within the network that had
the proper hearing aids that met your needs. The Plan denied your request. The Plan says you do not have outof-
network benefits.
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.
Review of the file show that you purchased the hearing aids on May 8, 2017 from a non-participating provider.
Your EOC states, hearing aids must be ordered from the supplemental hearing vendor. The requested provider
in this case is not a network provider with the Plan. The Plan has network providers available who can provide
the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no
exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does
not have to pay for the hearing aids purchased on May 8, 2017 from a non-participating provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for the services from November 20, 2019
through December 27, 2019 provided by multiple providers.
You asked the Plan to waive the cost-sharing for the services. You say that you are appealing your cost-share
responsibility for the services you received. The Plan denied your request. The Plan says the claims were
processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance).
From November 20, 2019 -December 27, 2019 you were present for multiple services: dental services,
ambulance transport, inpatient hospital care, physician services, X-ray, vision services, and physical therapy
evaluation performed by multiple providers. All claims were reviewed and have been processed correctly
according to your benefits and plan design. 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 cost-sharing for the
services from November 20, 2019 through December 27, 2019 provided by multiple providers.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from January 31, 2020 to February 1, 2020.
You asked the Plan to pay for acute inpatient hospital care. You say that criteria supports the level of care provided by your facility. The Plan denied your request. The Plan says that there was no criteria for inpatient admission.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. The record did not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department and/or observation care) would span two midnights. Our physician reviewer found that the enrollee's condition did not meet Medicare criteria for acute inpatient hospital 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 acute inpatient hospital care have not been met. Therefore, we decided that the
Plan does not have to pay for the acute inpatient hospital care provided from January 31, 2020 to February 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics. You asked the Plan to pre-approve footwear and foot inserts. You say that you need the orthotics because of complications from a surgery. The Plan denied your request. The Plan says this item is not a covered benefit. Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
You asked the Plan to pre-approve Prolia. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not medically necessary.
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 Prolia. Our reviewer says that the documentation does not support that the requested drug is medically reasonable or necessary. Our physician reviewer found the enrollee was initially diagnosed with stage T1c Gleason's grade 3+3 adenocarcinoma in 2015 and has been on active surveillance. The enrollee's PSA was elevated at 47.6 ng/mL prompting CT scan that revealed extensive metastatic disease in lymph nodes and bone. Prolia is indicated for treatment to increase bone mass in men with osteoporosis at high risk for fracture, defined as a history of osteoporotic fracture, or multiple risk factors for fracture; or patients who have failed or are intolerant to other available osteoporosis therapy or as a treatment to increase bone mass in men at high risk for fracture receiving androgen deprivation therapy for nonmetastatic prostate cancer. The medical records provided do not indicate that these criteria have been met. 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.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of IUD and Kyleena 19.5mg device.You asked the Plan to pre-approve the procedure. You say that this is medically necessary.The Plan denied your request. The Plan says this device may be used for in a Medicare member with abnormal uterine bleeding with documented hyperplasia without atypia.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 procedure. Our reviewer says that the requested procedure is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a diagnosis of abnormal uterine bleeding ongoing since 2015. Review of the compendia does not support the use of Kyleena for the treatment of dysfunctional bleeding. The records do not support the trial and failure of oral progestin containing products. Without the support of the documentation and literature, medical necessity cannot be determined.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 procedure have not been met.Therefore, we decided that the Plan does not have to pre-approve insertion of IUD and Kyleena 19.5mg device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CPAP and supplies to be provided by an out of network provider.
You asked the Plan to pre-approve a CPAP and supplies from an out-of-network provider. You say that you want to provide the items. The Plan denied your request. The Plan says they have in-network providers available for the enrollee's CPAP and supplies.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a CPAP and supplies to be provided by an out of network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveRepatha.You asked the Plan to pre-approveRepatha. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested drug is not a covered benefit.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-approveRepatha.Benefits for Repathamay be available under Medicare PartD.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthoses and suspension sleeves provided on March 20, 2020.
You asked the Plan to pay for the knee orthoses (L1851) and suspension sleeves (L2397). You say that the orthoses were medically necessary. The Plan denied your request. The Plan says they were unable to discover any evidence of an established relationship between the member and the ordering physician.
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 knee orthoses (L1851) and suspension sleeves (L2397). Our reviewer says that the orthoses are not medically reasonable and necessary. Our physician reviewer found the enrollee's chief complaints were right knee pain and left knee pain. The documentation in the case file does not support that the requested knee orthoses with sleeves were medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. There is no documentation of recent injury to, or recent surgical procedure on, either of the enrollee's knees, and there is insufficient credible objective documentation of joint laxity. The item coded L2397 (sleeve) is not separately payable when the base item is not covered.
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 knee orthoses (L1851) and suspension sleeves (L2397) have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthoses and suspension sleeves provided on March 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for intraoral periapical each additional x-ray (D0230x5) provided February 7, 2020. You asked the Plan to pay for the dental services. You say that before you went to the dentist you called and was told that the plan will pay 100%. You are a senior citizen, disabled and on a fixed income. You can in no way pay for this bill. The Plan denied your request. The Plan says this service exceeds the benefit frequency limitation. 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. This health plan contract allows coverage for intraoral-periapical x-rays once per calendar year. The plan had approved payment for intraoral-periapical first x-ray (D0220) that was rendered on this same date of service. Therefore this benefit has been exhausted. 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 pay for intraoral periapical each additional x-ray (D0230x5) provided February 7, 2020.