Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on August 25, 2018.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was submitted after the timely filing limit.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service. The record shows that a claim for the services was not filed until October 17, 2019. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the services provided on August 25, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for endodontic therapy provided on March 27, 2020.
You asked the Plan to pay for endodontic therapy. You say that you had pain and had to go back. You say that
you don't feel responsible for the root canal. The Plan denied your request. The Plan says your annual
maximum was met.
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, there is an annual maximum amount of
$2,500. The Plan paid $2,500 toward your dental benefits prior to receiving endodontic therapy on March 27,
2020. Therefore, we decided that the Plan does not have to pay for endodontic therapy provided on March 27,
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Continuous Glucose Monitor (CGM) (K0553).
You asked the Plan to pre-approve the CGM. You say that the CGM is medically necessary for diabetes management. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that a CGM is covered when the beneficiary is insulin-treated with multiple (three or more) daily injections of insulin. We looked at the file and Medicare rules. The records provided and the request from the physician note that the enrollee is not currently injecting insulin. The records show the enrollee only uses oral medications for diabetes management. Based on this information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Continuous Glucose Monitor (CGM) (K0553).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.You asked the Plan to pre-approve IRF care. You say that this is medically necessary.The Plan denied your request. The Plansayscare could be received in another setting.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 the records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a SNF level of care. Ongoing pain medication and other medication management, skin care, and daily therapy can be provided at a SNF. A less intensive, longer duration of therapy will allow for measurable gains to be attained within a reasonable, and predicted period. An IRF intensity is not warranted.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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
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 foot orthotics. You say that you would like reconsideration because the member has been using orthotics for many years and new orthotics will lessen the member's ankle and lower back pain. 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 the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that this item should be approved. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair 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-approve a shower chair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forspecialist services provided on October 8, 2019.You asked the Plan to waive the copayment forspecialist services. You say that you think that this is just greed on the providers part.The Plan denied your request. The Plan says the correct copayment has been applied.Therules 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 $30 copayment for physician services/in-network/specialist services. You have been asked to pay a $30 copayment for specialist services. specialist services fall within the physician services/in-network/specialist services benefit category. This means that you have been asked to pay the correctamount 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 forspecialist services provided on October 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complex power wheelchair.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered for use in a SNF.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home. Records show that these services is being requested for use in a SNF or hospital. Therefore, we decided that the Plan does not have to pre-approve a complex power wheelchair.
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 for the enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee can remain in the current acute care location, until such time that no further acute level care is needed. 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 admission. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review indicates that the documentation provided does not indicate that the enrollee requires admission to a LTACH. She continues to require acute level of care hospital services and is receiving appropriate care at the present acute care facility. The review has determined that the enrollee does not require services at the LTACH that are not available at the acute care hospital where she 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 and able to be furnished safely and effectively only on an inpatient basis. 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a long term acute care hospital for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested acupuncture services.
You asked the Plan to pre-approve the acupuncture services. The Plan denied your request. The Plan says you
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 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 services at issue in this appeal. We found no exception that would require the
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the
requested acupuncture services.
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 (OON) provider.You asked the Plan to pre-approve the office visit with an out-of-network provider. You say that you would like reconsideration because the member requires a provider that can speak Korean.The Plan denied your request. The Plan says there are network providers available who can render this service and provide translation services.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 the medical services to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental surgery in an outpatient surgery center.
You asked the Plan to pre-approve the surgery. You say that you were told that you could get this under a
medical exception.
The Plan denied your request. The Plan says this is not a covered service under Medicare Part B.
Medicare generally does not cover dental services. The Plan follows the same rule.
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement
of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or
paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve dental surgery in an
outpatient surgery center.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to approve in-network coverage for gynecological care from an out of
network (OON) provider.
You asked the Plan to approve in-network coverage for the OON gynecology services. You say that you would
like to be able to continue to see this provider who has left the network because you have been under her care
for more than 20 years. She has provided care to many of your relatives and delivered your grandsons. She also
comes to a nearby area periodically which is helpful because you are not able to drive. You believe that this
should continue to be covered as in-network care. The Plan denied your request. The Plan says your plan's
network has gynecology providers who are able to assume your care. You are not in active treatment for any
condition and there is no service offered by the OON provider that is not available in the network. Please note
that you may continue to see this provider with out of network cost sharing.
Medicare rules say that plans can require enrollees to get care from network providers in order to get innetwork
cost sharing. The contract with the Plan says that the Plan has to approve in-network coverage for 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. Although you do have a history with this
provider, there is no medical reason noted that network providers are inadequate to meet your needs. We found
no exception that would require the Plan to approve in-network coverage for these items/services. Therefore,
we decided that the Plan does not have to approve in-network coverage for gynecological care from an out of
network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stair glide.
You asked the Plan to pre-approve a stair glide. You say that this chair is necessary for your due to your health conditions and you would like to appeal. 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 stair lifts are not covered because they are not primarily medical in nature. While a stair lift 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-approve a stair glide.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on March 6, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network deficiency for the services.
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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on March 6, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that you are growing weaker in your current location and
want to start your recovery to go home. The Plan denied your request. The Plan says the denial of authorization
for IRF service is correct.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
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 the complexity of your nursing, medical, and rehabilitation needs does not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require
treatment by multiple therapies in an intensive rehabilitation therapy program. There is not a reasonable
expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy
program provided in an IRF. Your rehabilitation needs can be met in another setting such as a skilled nursing
facility.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an oral surgery consultation visit.
You asked the Plan to pre-approve the visit. You say that this is medically necessary. The Plan denied your request. The Plan says you do not have a diagnosis of TMJ, and you are not currently receiving or preparing for radiation therapy to the mouth.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve an oral surgery consultation visit.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Belbuca Mis 300 mcg for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your
request. The Plan says the enrollee has no commercial pharmacy benefit administered by the plan.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Belbuca Mis 300 mcg for
the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Sumatriptan (J8499).
You asked the Plan to pre-approve the Sumatriptan. You say that you would like reconsideration because this drug is medically necessary. The Plan denied your request. The Plan says this drug is not a covered benefit under Medicare 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 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 Sumatriptan (J8499).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair, shower grab bars, and a shower head
extension (E0241, A9286, E0240).
You asked the Plan to pre-approve the a shower chair, shower grab bars, and the shower head extension. You
say that the items are medically necessary. The Plan denied your request. The Plan says these items are not
covered benefits.
The Plan must follow Medicare rules. Medicare rules say that shower chairs, grab bars, and a shower head
extension are not covered because they are not primarily medical in nature.
While the items may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items.
Therefore, we decided that the Plan does not have to pre-approve a shower chair, shower grab bars, and a
shower head extension (E0241, A9286, E0240).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the cervical collar (L0180) provided February 25, 2020.
You asked the Plan to pay for the cervical collar. You say that you have attached all the supporting documentation. Please reprocess claim. The Plan denied your request. The Plan says the records provided do not support the service billed.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the cervical collar. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation in the case file does not support that the requested cervical collar was medically reasonable and necessary for the enrollee in this case. An appropriate history and a physical examination of the neck would reasonably be required to adequately assess whether the cervical collar was medically necessary for an enrollee. The documentation does not support that the cervical collar was medically reasonable and necessary for the enrollee in this case, as there is no documented physical examination of the neck, and no documentation of a neck problem requiring a cervical collar. 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 cervical collar have not been met. Therefore, we decided that the Plan does not have to pay for the cervical collar (L0180) provided February 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Continuous Glucose Monitor (CGM) (K0553).You asked the Plan to pre-approve the CGM. You say that the CGM is medically necessary.The Plan denied your request. The Plan says rules for coverage have not been met.The Plan must follow Medicare rules. Medicare rules say that a CGM may be covered when the beneficiary is insulin-treated with multiple (three or more) daily injections of insulin. We looked at the file and Medicare rules. The record shows the enrollee does not inject insulin and only takes oral medication for diabetes control. Based on this information, we decided that Medicare rules for coverage of the CGM have not been met.Therefore, we decided that the Plan does not have to pre-approve a Continuous Glucose Monitor (CGM) (K0553).