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

We decided that the Plan does not have to pre-approve a heavy-duty power operated vehicle and battery.
You asked the Plan to pre-approve a heavy-duty power operated vehicle and battery. You say that your body
has limitations with bone on bone ankle and knee. The Plan denied your request. The Plan says you do not
meet criteria for the requested items.
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 do not have a mobility deficit that impairs your participation in MRADLs or your
condition can be improved by a walker, cane or manual wheelchair. 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-approve a
heavy-duty power operated vehicle and battery.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional non-emergency transportation trips.

You asked the Plan to provide coverage for the additional non-emergency transportation trips. You say that you are unable to drive due to the dislocation of your right arm and you need additional transportation to attend your physical therapy visits. The Plan denied your request. The Plan says you have used up all of the 42 one-way trips for this year.

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 42 one-way trips per year.

We looked at your request, the records in the case file, and the rules. The file shows you have used all of the 42 one-way trips for this year. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of non-emergency transportation. Therefore, we decided that the Plan does not have to provide coverage for additional non-emergency transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided by an out-of-network provider on January 4, 2021.
You asked the Plan to pay for the office visit. You say that the treatment provided was medically necessary and the medical records justify the medical services. You say that the treatment is within the medical practice standards and the denial should be overturned. The Plan denied your request. The Plan says the non-emergent services were not authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan 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 office visit provided by an out-of-network provider on January 4, 2021.
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. The Plan denied your request. The Plan says the enrollee does not require complex wound care of daily physician supervision.
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 in this case, the enrollee was admitted with sacral decubitus and osteomyelitis. She requires wound vac change twice weekly. She continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that she is not currently receiving but that would be available at the LTACH facility. Therefore, the requested LTACH services are not medically reasonable and 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 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve adjunctive pre-diagnostic testing (D0431), scaling and root planing (D4341 x 4), localized delivery of antimicrobial agents (D4381 x 8), and unspecified periodontal service (D4999 x 4).
You asked the Plan to pre-approve the dental services. You say that you are still in desperate need of having this work done. You also say that you did not withdraw your appeal request. The Plan denied your request. The Plan says adjunctive pre-diagnostic testing is not listed as a covered service. The Plan says that scaling and root planing are not listed as covered services. The Plan says that localized delivery of antimicrobial agents is not listed as a covered service. The Plan also says that unspecified periodontal services are not listed as covered services either.
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 dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve adjunctive pre-diagnostic testing (D0431), scaling and root planing (D4341 x 4), localized delivery of antimicrobial agents (D4381 x 8), and unspecified periodontal service (D4999 x 4).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the diagnostic mammogram and breast tomosynthesis you had at an out-of-network hospital on January 6, 2021.
You asked the Plan to waive the copayments for the diagnostic mammogram and breast tomosynthesis. You say that you believe this service should be covered in full. The Plan denied your request. The Plan says you were charged these copayments 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 $70 copayment for diagnostic mammography services at an outpatient hospital facility and a $100 copayment for other diagnostic tests.
You have been asked to pay a $70 copayment for the diagnostic mammogram and a $100 copayment for the breast tomosynthesis. Because the allowed amount for the breast tomosynthesis ($22.36) is less than your copayment obligation, you are responsible for the full allowed amount for this service, for a total of $92.36 due. 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 diagnostic mammogram and breast tomosynthesis you had at an out-of-network hospital on January 6, 2021.
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 IRF care is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for IRF care have not been met.
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 based on the medical records provided the complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary
approach to rehabilitation care. He is on oral medications and subcutaneous sliding scale insulin and is reported to have stabilized. Although the patient does require physical therapy and occupational therapy services, based on the medical records provided the patient does not require an intensive inpatient rehabilitation therapy program. Care at the skilled nursing facility level appears to be appropriate in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pre-approve the additional twelve (12) occupational therapy visits and twelve
(12) physical therapy visits.
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your
request. The Plan says that the requested visits exceed the treatment plan recommended by your therapy team.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. It appears that the plan's contracted delegate was provided the records for these
services and has failed to forward them to support the decision to deny based on no medical necessity.
Therefore, we decided that the Plan has to pre-approve the additional twelve (12) occupational therapy visits
and twelve (12) physical therapy visits.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a surgical placement of implant (D6010), a custom fabricated abutment (D6057), and an abutment supported crown (D6058).
You asked the Plan to pre-approve a surgical placement of implant, a custom fabricated abutment, and an abutment supported crown. You say that the services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are not covered 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 a surgical placement of implant (D6010), a custom fabricated abutment (D6057), and an abutment supported crown (D6058).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound of the heart provided on February 4, 2021.

You asked the Plan to waive the copayment for an ultrasound of the heart. You say that you disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 an $85 copayment for advanced imaging services provided at an outpatient hospital facility. 

You have been asked to pay an $85 copayment for an ultrasound of the heart. An ultrasound of the heart falls 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 copayment for an ultrasound of the heart provided on February 4, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided October 18, 2020.

You asked the Plan to pay for acute inpatient hospital care. You say that you would like reconsideration because the inpatient admission was medically necessary.The Plan denied your request. The Plan says the member did not meet 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. Our physician reviewer found the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the member's necessary hospital care (including earlier ED and/or observation care) would span two midnights.

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 October 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the preoperative visit you had on February
4, 2021.
You asked the Plan to waive the copayment for the preoperative visit. You say that you did not see the provider
whose name is on the bill for this copayment. You also say that there should be no applicable copayment for
this service because it was a preoperative visit. The Plan denied your request. The Plan says you were charged
this copayment correctly. The Plan says that under their Evidence of Coverage, there is no provision for a
waiver of copayments for preoperative visits.
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 $25
copayment for visits with a specialist.
You have been asked to pay a $25 copayment for the preoperative visit. Records show that the provider whose
name is on the bill is the billing provider. You actually saw a physician's assistant on this date of service.
Physician's assistant services are often billed under the name of a physician in their practice. That is why you
may not recognize the billing 's name. In addition, Medicare rules are very clear with regard to what services
are considered part of the surgery itself. According to Medicare rules, the only preoperative service that is
included in the cost of the surgery itself is a visit with the surgeon on the day before or the day of the surgery
itself. All other preoperative visits are separately payable, including preoperative services rendered by
providers other than the surgeon performing the surgery. This is why it was appropriate for your Plan to charge
a copayment for the visit you had on February 4, 2021. 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 preoperative visit you had on February 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the provisional crown (D2799) provided on December 10, 2019.
You asked the Plan to pay for the provisional crown.. You say that the provider performed this service without informing you of the cost or that it was not covered. The Plan denied your request. The Plan says this service is not covered by your dental benefit.
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 pay for the provisional crown (D2799) provided on December 10, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Oxycodone.

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 Oxycodone.

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: Surgery
Decision: Partially Favorable

We decided that the Plan has to reduce the copayment for the cystoscopy. We decided that the Plan does not have to reduce the copayment for surgery in an outpatient hospital facility.
You asked the Plan to reduce the copayment for the cystoscopy. You say that this procedure was done in an office and shouldn't be considered surgery. The Plan says that you were charged this copayment correctly.
We decided that the Plan has to waive the copayment charged for surgery in an outpatient hospital facility.
The medical records from this date of service clearly state that the procedure was an office-based procedure. Furthermore, the address where the services were rendered is not an outpatient hospital facility. It is not reasonable for the Plan to expect you to know that your doctor would bill this as an outpatient hospital surgery when the surgery was performed in an office setting. That is why it is not appropriate for the Plan to assess a copayment for surgery at an outpatient hospital facility.
We also decided that the Plan does not have to waive the office visit copayment for this cystoscopy service.
Your contract with the Plan clearly says that surgery services furnished in a physician's office fall in the physician's services benefit category. The correct copayment for surgery services performed in a specialist's office is $25. Therefore, we decided that the Plan may charge a $25 copayment for the cystoscopy you received.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory service (82728) provided on February 17, 2021.

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.

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 $5 copayment for other Medicare-covered laboratory tests that are not FIT tests.

You have been asked to pay a $5 copayment for the laboratory service provided. 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 laboratory service (82728) provided on February 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a roll-a-bout, platform crutch (E1399).
You asked the Plan to pre-approve the platform crutch. You say that approximately 10 years ago the plan granted you a roll-a-bout. Your current roll-a-bout is used on the 1st floor. You are now 90 and you would profit from a second roll-a-bout on the second floor. The Plan denied your request. The Plan says Medicare criteria for walking equipment do not cover this type of crutch.
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 the platform crutch have not been met. Therefore, we decided that the Plan does not have to pre-approve a roll-a-bout, platform crutch (E1399).