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

We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) services provided from August 9, 2019 to September 19, 2019. You asked the Plan to waive the copayment for the SNF services. You say that you were told your plan would cover these services. The Plan denied your request. The Plan says that cost shares are a contractual obligation. 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 $170.50 copayment for each day for days 21 to 100 of SNF care. You have been asked to pay a $3,580.50 copayment for the SNF services. The SNF services fall within the days 21 to 100 of SNF care benefit category. The file indicates you were in a SNF for forty-one (41) days. You have been charged a copayment of $170.50 for twenty-one (21) days. 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 skilled nursing facility (SNF) services provided from August 9, 2019 to September 19, 2019.
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 the item is necessary to prevent falling.The Plan denied your request. The Plan says the 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the CardioMEMS Heart Failure System.
You asked the Plan to pre-approve the CardioMEMS Heart Failure System. You say that you need this
procedure. The Plan denied your request. The Plan says you are not in an approved clinical study and therefore
this procedure is not covered.
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 CardioMEMS Heart Failure System.
Our reviewer says that the requested items/services are considered experimental and investigational in this case. Our physician reviewer found in this circumstance therapy change based on data obtained from a
CardioMEMs device has been demonstrated in only one trial to help reduce hospital readmission compared to
standard medical therapy. Moreover, concerns have been raised about potential bias in this trial calling into
question the results. Therefore, the efficacy of the CardioMEMS device is uncertain at this time according to
leading authorities and not recommended in current guidelines for the treatment of heart failure. Medicare
coverage criteria are not met since the device should still be considered experimental or investigational.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of CardioMEMS Heart Failure System have not been met. Therefore, we decided
that the Plan does not have to pre-approve the CardioMEMS Heart Failure System.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to providea Group 3 multiple power option wheelchair and accessories.You asked the Plan to providea Group 3 multiple power option wheelchair and accessories. You say that you need a power wheelchair.The Plan denied your request. The Plansays the requested power wheelchair exceeds yourneeds at this time.The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for enrollees who have a mobility limitation that is due to:1. A neurological condition;2. Myopathy; or3. Congenital skeletal deformity.The file does not show that you have a mobility limitation that is due to a neurological condition, myopathy or congenital skeletal deformity.Therefore, we decided that the Plan does not have to providea Group 3 multiple power option wheelchair and accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eight additional chiropractic visits
You asked the Plan to pre-approve the visits. You say that this is medically necessary. The Plan denied your request. The Plan says there is nothing in the supplied documentation that supports that the services will be of such a level of complexity and sophistication that they can only be safely and effectively performed by a chiropractor.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The rules say that Medicare does not cover chiropractic maintenance care. 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 visits Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found the provider submits two chart notes dated February 5, 2020 and March 11, 2020. Finding state spinal restrictions/subluxations in the pelvis, lumbar and sacroiliac areas and thoracic spine, pain and tenderness in the cervical thoracic and lumbosacral spine, postural imbalances, muscle spasms of several muscles and a notation of mildly reduced cervical and lumber extension and flexion motions. There is no evidence of significant findings such as neurological deficits, muscular weakness, significantly decreased quantifiable measures of strength, decreased reflexes or sensory, significantly decreased ranges of motion, multiple orthopedic findings or any significant findings to support chiropractic treatment. Medicare guidelines state there must be a significant health problem in the form of neuro musculoskeletal condition necessitating treatment and the manipulative services must have a direct therapeutic relationship to the patient's condition.' The enrollee's condition does not support long term, going chiropractic 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 the visits have not been met. Therefore, we decided that the Plan does not have to pre-approve eight additional chiropractic visits
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay foran alveoloplasty in conjunction with extractions and two removals of torus palatinus.You asked the Plan to pay forthe alveoloplasty and removals of torus palatinus. You say that the dentist needs to reshape a bone so that you can get your dentures.The Plan denied your request. The Plan says these services 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 pay foran alveoloplasty in conjunction with extractions and two removals of torus palatinus.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay further forthe dental crown rendered to you on November 12, 2019.You asked the Plan to pay further forthese services. You say that you disagree with the amount paid by the plan.The Plan denied your request. The Plan says the claim was processed correctly.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services up to $100 per tooth with a 50% coinsurance.The file shows that you received a crown from an in-network provider on November 12, 2019. The Plan applied the maximum benefit of $100 per tooth for crowns. You are being asked to pay a 50% coinsurance for these services, based on the contract with the Plan. Based on this information, the claim was processed correctly by the Plan. Therefore, we decided that the Plan does not have to pay further forthe dental crown rendered to you on November 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthotics provided on October 2, 2019.
You asked the Plan to pay for the knee orthotics. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services were not billed correctly.
The Plan must follow Medicare rules. The rules say that diagnosis codes must be billed with the most precise code that most fully explains the narrative description of the symptom or diagnosis. We looked at the file and Medicare rules. The file shows that the knee orthotics were billed with one or more diagnosis codes that were inappropriately coded. Medicare rules say that some ICD-10-CM codes indicate laterality, specifying whether the condition occurs on the left, right or is bilateral. It is not appropriate to report unspecified, or left and right diagnosis codes when a more specific, in this case; bilateral code is available. Therefore, we decided that the Plan does not have to pay for the knee orthotics provided on October 2, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the abutment supported porcelain/ceramic crown (D6058) provided on January 6, 2020.You asked the Plan to pay for the abutment supported porcelain/ceramic crown. You say that it was your understanding that the coverage of the $1,000 annual maximum benefit would include this abutment work.The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan.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 abutment supported porcelain/ceramic crown (D6058) provided on January 6, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approvemolecular genetic test.You asked the Plan to pre-approvemolecular genetic test. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services are 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 molecular genetic test. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a diagnosis of Secondary polycythemia. His past medical history is notable for diabetes. The duration of the enrollee's polycythemia is not documented. There is no documentation of a serum EPO level. The documentation does not sufficiently support that molecular and genomic testing is likely to impact this enrollee's management. Therefore, the enrollee does not meet criteria for the requested services.Review of the file shows that the plan uses Local Coverage Determination, LCD L37606 to support their denial. However, LCD L37606 is not valid for the enrollee's homestate of NJ. Therefore, we cannot use LCD L37606 to substantiate our decision.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of molecular genetic test have not been met. Therefore, we decided that the Plan does not have to pre-approvemolecular genetic test.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve FreeStyle Libre Continuous Glucose Monitoring
System.
You asked the Plan to pre-approve a continuous glucose monitor. You say that the enrollee has been using the
CGM and is at high risk without it. The Plan denied your request. The Plan says criteria for a CGM is not met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they
are medically reasonable and necessary and replace a blood glucose monitor.
We looked at the file and Medicare rules. The enrollee is not insulin treated. Based on this information, we
decided that Medicare rules for coverage of a continuous glucose monitor have not been met. Therefore, we
decided that the Plan does not have to pre-approve FreeStyle Libre Continuous Glucose Monitoring System.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve N95 respirator masks.
You asked the Plan to pre-approve N95 respirator masks. You say that you cannot leave your house or have
anyone in your house without a mask. The Plan denied your request. The Plan says Medicare rules say that face
masks are categorized as non-reusable disposable items and are not payable by Medicare.
The Plan must follow Medicare rules. Medicare rules say that disposable masks are not covered.
We looked at the file and Medicare rules. While face masks may be appropriate in this case, neither the Plan
nor Medicare offers coverage of this item. Based on this information, we decided that Medicare rules for
coverage of N95 respirator masks have not been met. Therefore, we decided that the Plan does not have to pre-approve
N95 respirator masks.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea FreeStyle Libre Continuous Glucose Monitoring System.You asked the Plan to pre-approvea continuous glucose monitor. You say that a CGM would be highly beneficial for the enrollee to check sugars.The Plan denied your request. The Plan says a CGM is not covered by Medicare when an enrollee is not on insulin.The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor.We looked at the file and Medicare rules. The enrollee is not insulin treated and therefore does not meet the Medicare coverage criteria for a CGM. Based on this information, we decided that Medicare rules for coverage of a continuous glucose monitor have not been met.Therefore, we decided that the Plan does not have to pre-approvea FreeStyle Libre Continuous Glucose Monitoring System
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for an additional 15 extra miles for routine transportation for doctor's appointments.You asked the Plan to provide coverage for an additional 15 extra miles for routine transportation. You say that it was not made clear to you that there was a limit of 75 miles for the transportation benefit. The Plan denied your request. The Plan says the benefit is limited to ground transportation only to destinations within 75 miles of the pick-up location.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. We looked at your request, the case file and the Plan's rules.The Plan says that the benefit is limited to ground transportation only to destinations within 75 miles of the pick-up location.Therefore, we decided that the Plan does not have to provide coverage for an additional 15 extra miles for routine transportation for doctor's appointments.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Always or Kotex pads.
You asked the Plan to pre-approve these services. You say that this used to be covered. The Plan denied your request. The Plan says that this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve Always or Kotex pads.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair and attachments for the enrollee.
You asked the Plan to pre-approve these services. The Plan denied your request. The Plan says that this is not medically necessary.
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for enrollees who have a mobility limitation that is due to: 1. A neurological condition; 2. Myopathy; or 3. Congenital skeletal deformity. The file does not show that the enrollee has a mobility limitation that is due to a neurological condition, myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair and attachments for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an x-ray to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve an x-ray. You say that you do not want to risk your health due to Covid 19 and would prefer to have your x-ray done at your doctor's office. The Plan denied your request. The Plan says there are in-network providers available for these 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 an x-ray to be provided by an out of network (OON) provider.
Please contact the Plan for a list of in-network providers available for these services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthoses (L1833-RT, L1833-LT, L2937-RT and L2937-LT) provided on December 13, 2019.You asked the Plan to pay for the knee orthoses. You say that you would like reconsideration because these supplies are medically necessary.The Plan denied your request. The Plan says no medical records were received to support the diagnosis on the submitted order.The Plan must follow Medicare rules. Medicare rules say that or any DMEPOS item to be covered by Medicare, the patient's medical record must contain sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use or replacement. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the knee orthoses have not been met. Specifically, the record indicates that the Plan requested information to support that the provider discussed the need for the billed supply codes. There is insufficient information to verify the billed codes.Therefore, we decided that the Plan does not have to pay for the knee orthoses (L1833-RT, L1833-LT, L2937-RT and L2937-LT) provided on December 13, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for acupuncture services provided on November 13, 2019 and December 9, 2019.
You asked the Plan to pay for the acupuncture services. The Plan denied your request. The Plan says acupuncture services are limited to 20 visits per Plan year. The limited number of services has been exceeded.
The rules say that acupuncture services are not covered by Medicare. However, the Plan offers an acupuncture benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers acupuncture with a limit of 20 visits per Plan year. We looked at the file and the Plan's rules. The file shows that you exceeded the limit of 20 acupuncture visits per Plan year as of the visit on November 13, 2019. Therefore, we decided that the Plan does not have to pay for acupuncture services provided on November 13, 2019 and December 9, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an oxygen concentrator.You asked the Plan to pre-approve an oxygen concentrator. You say that the enrollee needs an oxygen concentrator.The Plan denied your request. The Plan says the records sent in for review do not show that you meet the requirements for this service.The Plan must follow Medicare rules. The rules say that oxygen is coverable when medically necessary for patients with significant hypoxemia who meet certain blood gas evidence requirements. In addition, the patient must have tried other alternative treatments without complete success. The patient must meet one of the following blood gas levels:1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest;2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during sleep for a patient who have hypoxia symptoms during sleep;3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for patients who have hypoxia symptoms during exercise;4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of dependent edema, pulmonary hypertension, or erythrocythemia.We looked at the file and Medicare rules. Criteria is not met. Based on this information, we decided that Medicare rules for coverage of an oxygen concentrator have not been met.Therefore, we decided that the Plan does not have to pre-approve an oxygen concentrator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea power seat elevation feature (E2300) for the enrollee.You asked the Plan to pre-approvea power seat elevation feature. You say that this is essential for the enrollee to complete everyday tasks.The Plan denied your request. The Plan says that this is non-covered by Medicare.The Plan must follow Medicare rules. Medicare rules say that a power seatelevation feature is non-covered because it is not primarily medical in nature.Therefore, we decided that the Plan does not have to pre-approvea power seat elevation feature (E2300) for the enrollee.