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

We decided that the Plan does not have to pay for non-emergent transportation provided to the enrollee on May 17, 2019.
You asked the Plan to pay for non-emergent transportation. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are not medically necessary.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of non-emergent transportation have not been met. The enrollee did not require any medical intervention during her transport and she refused the ordered supplemental oxygen, which per the physician was the reason for the use of an ambulance transport. Therefore, we decided that the Plan does not have to pay for non-emergent transportation provided to the enrollee on May 17, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveLTACH services for the enrollee.You asked the Plan to pre-approvethe LTACH services. You say that theenrollee's care will be better provided in the LTACH setting.The Plan denied your request. The Plan says the enrollee's current needs are being met in the current acute setting.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 physician reviewer found that the enrollee is currently undergoing treatment at an acute care hospital (ACH) following multiple surgeries for a small bowel obstruction. The enrollee's post-operative course was complicated by wound dehiscence and the need for bowel rest. The enrollee is not intubated/ventilated. The enrollee is tolerating tube feedings and oral intake. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH.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-approvelong term acute care hospital (LTACH) services for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says to transfer to an LTACH, you must have been on a breathing machine for a long time, such as 21 days.
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 LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital after suffering a hemorrhagic stroke. The enrollee was intubated/ventilated and subsequently received a tracheotomy. The enrollee appears to be minimally responsive and there is no documentation that she is appropriate for ventilator weaning. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs. 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 admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for progressive lens, per lens (CPT Code V2781) provided by a contracted provider on August 13, 2019.
You asked the Plan to pay for the progressive lens. You say that you purchased eyeglasses after cataract surgery. The Plan denied your request. The Plan says your plan does not cover progressive lenses.
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 pay for are considered routine vision services or eyewear. Progressive lenses are not covered. Therefore, we decided that the Plan does not have to pay for progressive lens, per lens (CPT Code V2781) provided by a contracted provider on August 13, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bed rails.
You asked the Plan to pre-approve bed rails. You say that you need this to assist you with getting up. The Plan denied your request. The Plan says that this is only covered for a covered hospital bed.
The Plan must follow Medicare rules. Medicare rules say that side rails are only covered when they are an integral part or accessory to a covered hospital bed. We looked at the file and Medicare rules. The file indicates the bed rails are being requested for your regular bed and not a hospital bed. Based on this information, we decided that Medicare rules for coverage of bed rails have not been met. Therefore, we decided that the Plan does not have to pre-approve bed rails.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99214) provided on September 5, 2019 by an out of network provider.
You asked the Plan to pay for an office visit. You say that these services were medically necessary and an integral part of the patient's medical care. The Plan denied your request. The Plan says in order for medical services to be covered under the enrollee's plan they must be received from providers contracted with the Plan. The Plan says the only exceptions to this are in cases of urgent or emergent needed care.
The Plan also says that if the medical care required cannot be provided by contracted, in-network providers then the Plan has given prior authorization for such care. 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 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 an office visit (99214) provided on September 5, 2019 by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 17, 2019 by the out of network provider.
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 were rendered by an out-of-network provider without 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 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 medical services provided on July 17, 2019 by the out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a wrist-hand orthosis (L3916) provided to the enrollee on September 11, 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 does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for a wrist-hand orthosis (L3916) provided to the enrollee on September 11, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 2D oral or facial photographic image (D0350), diagnostic casts (D0470), cone beam CT of both jaws (D0367 x 2), 16 additional surgical extractions (D7210), 8 implants (D6010), 8 prefabricated abutments (D6056), radiographic or surgical implant index (D6190 x 2), and the complicated suture (D7912) provided from January 8, 2019 to March 18, 2019.
You asked the Plan to pay for the 2D imaging, diagnostic casts, cone beam CT of both jaws, 16 additional surgical extractions, 8 implants, 8 prefabricated abutments, 2 radiographic or surgical implant index, and the complicated suture.
You say that you know that implants are not covered by the Plan but that dentures are covered. You also say that the anesthesia should have been reimbursed. The Plan denied your request. The Plan says that the 2D imaging, diagnostic casts, cone beam CT of both jaws, implants, prefabricated abutments, radiographic or surgical implant index, and the complicated suture are not listed as covered service. The Plan also says that the frequency limit of up to 2 surgical extractions per year has been exceeded.
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 and extractions are a covered service, the frequency limit has been exceeded. The record shows that the Plan has paid for 2 extractions that you received on March 18, 2019. Additionally, the remaining dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 2D oral or facial photographic image (D0350), diagnostic casts (D0470), cone beam CT of both jaws (D0367 x 2), 16 additional surgical extractions (D7210), 8 implants (D6010), 8 prefabricated abutments (D6056), radiographic or surgical implant index (D6190 x 2), and the complicated suture (D7912) provided from January 8, 2019 to March 18, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for psychotherapy provided on August 26, 2019.
You asked the Plan to waive the deductible for psychotherapy. You say that you were informed the provider was in-network. You say that you are not able to pay the bill. The Plan denied your request. The Plan says the deductible applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that your deductible is $2,000. This is the amount you have to pay out-of-pocket before we will pay our share for your covered in-network medical services. Out-of-network services are not excluded from the deductible. The item or service you asked the Plan to waive the deductible for falls within the "Outpatient mental health care" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $2,000 deductible applies to out-of-network services. This cost sharing is a contractual obligation that had not been met at the time psychotherapy was received on August 26, 2019. Therefore, we decided that the Plan does not have to waive the deductible for psychotherapy provided on August 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a respiratory assist device, bi-level pressure and humidifier.
You asked the Plan to pre-approve a BiPAP device and humidifier. You say that the enrollee needs a BiPAP and humidifier. The Plan denied your request. The Plan says there is no documentation that a CPAP was tried and proven ineffective.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a BiPAP device and humidifier have not been met. Therefore, we decided that the Plan does not have to pre-approve a respiratory assist device, bi-level pressure and humidifier.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the ECG provided on September 27, 2019
and October 3, 2019.
You asked the Plan to waive the copayments for the ECG's. You say that you shouldn't be responsible because
the office is in the hospital. The Plan denied your request. The Plan says the copayments 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 $100
copayment for diagnostic procedures and tests at an in-network outpatient hospital.
You have been asked to pay a $53.45, which is less than the standard $100 copayment for each ECG. The total
amount you owe is $106.90 ($53.45/ECG x 2 ECG's = $106.90). The ECG's fall within the "Outpatient
diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the
copayments for the ECG provided on September 27, 2019 and October 3, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for home blood glucose monitor (CPT Code E0607), blood glucose test or reagent strips for home blood glucose monitor, per 50 strips (CPT Code A4253), lancets, per box of 100 (CPT Code A4259), normal, low, and high calibrator solution/chips (CPT Code A4256) and spring-powered device for lancet, each (CPT Code A4258) provided to the enrollee from July 29, 2019 through October 17, 2019.
You asked the Plan to pay for the DME. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not supported.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. HCPCS Code(s) E0607 - NU, KX, A4253 - NU, KS, KL (6 Units), A4259 - KX, KL (3 unites), A4256 - K, KL (3 Units), A4258 - KX, KL (3 units) - dates of service July 29, 2019 - October 17, 2019. 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 submitted. Therefore, we decided that the Plan does not have to pay for home blood glucose monitor (CPT Code E0607), blood glucose test or reagent strips for home blood glucose monitor, per 50 strips (CPT Code A4253), lancets, per box of 100 (CPT Code A4259), normal, low, and high calibrator solution/chips (CPT Code A4256) and spring-powered device for lancet, each (CPT Code A4258) provided to the enrollee from July 29, 2019 through October 17, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient level of care following surgery.
You asked the Plan to pre-approve acute inpatient level of care. You say that the requested inpatient level of care is medically necessary. The Plan denied your request. The Plan says the requested inpatient level of care is not medically necessary.
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 acute inpatient level of care. Our reviewer says that the requested inpatient level of care is not medically necessary. Our physician reviewer found the enrollee is requesting an inpatient level of care for approved total knee arthroplasty surgery. The medical records do not justify inpatient admission. Observational stay is medically appropriate. Inpatient admission for TKR surgery is not needed at this time. 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 level of care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient level of care following surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network provider.
You asked the Plan to pre-approve chiropractic services. You say that your knee is causing you a lot of pain and you want to avoid knee replacement surgery, and the nearest in-network provider is more than 50 miles away. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this provider is out-of-network with the Plan and you can be treated by an in-network chiropractor.
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 pre-approved care. Medicare rules say that plans must make care accessible to enrollees. According to Medicare rules, care is considered accessible to an enrollee if contract providers are available within reasonable distance and travel time from the enrollee's home. The Plan says that enrollees must use contract 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. These providers are within a reasonable distance and travel time from your home.
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 the medical services to be provided by the out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the bone replacement graft for ridge preservation and therapeutic parenteral drug.
You asked the Plan to pre-approve the bone replacement graft and therapeutic parenteral drug. You say that you have a tooth that created a hole in your mouth. You also say that you would like to have a bone replacement graft to cover the hole and the therapeutic drug to help. The Plan denied your request. The Plan says these services are not covered under your benefit package.
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 the bone replacement graft for ridge preservation and therapeutic parenteral drug.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lipitor tablets 10mg.
You asked the Plan to pre-approve Lipitor tablets 10mg. You say that the requested medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit or a separate pharmacy benefit, therefore self-administered drugs do not meet the criteria for coverage.
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 Lipitor tablets 10mg.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says he enrollee is receiving appropriate inpatient acute care, and does not require transfer to the LTACH.
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 LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is currently undergoing treatment at an ACH for altered mental status, in the setting of liver failure. The enrollee was intubated/ventilated and subsequently received a tracheotomy. He has since been weaned from the ventilator. The enrollee continues to have altered mental status and his long-term prognosis appears to be poor. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs. 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 admission to a long term acute care hospital (LTACH) for the enrollee.