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

We decided that the Plan does not have to pre-approve a power tilt and recline and a power seat elevator.
You asked the Plan to pre-approve the wheelchair accessories. You say that this is medically necessary. The Plan denied your request. The Plan says the tilt is not covered as there is no documentation of high risk for development of a pressure ulcer. The elevator is not covered as it is not primarily medical in nature.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The power seat elevator 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. Regarding the power tilt and recline, our doctor found that there is no documented pressure ulcer formation, or inability to self-pressure relief. A power tilt and recline feature is a convenience item, and is deemed not medically necessary. Therefore, we decided that the Plan does not have to pre-approve a power tilt and recline and a power seat elevator.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided from May 13, 2019 through May 19, 2019.
You asked the Plan to pay for these drugs. You say that this medication was required after your surgery. The Plan denied your request. The Plan says that non-emergency medications obtained outside the United States 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 pay for the self-administered drugs provided from May 13, 2019 through May 19, 2019.
Benefits for these drugs 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the belt, strap, sleeve, garment, or covering provided on November 19, 2019.
You asked the Plan to pay for the elbow strap (A4467). You say that you cannot pay for the elbow strap and the Plan should pay this claim. The Plan denied your request. The Plan says this item is not covered by Medicare or the Plan.
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. The elbow strap is not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of the elbow strap (A4467) have not been met. Therefore, we decided that the Plan does not have to pay for the belt, strap, sleeve, garment, or covering provided on November 19, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for lab tests provided on November 1, 2019 by an out of network
(OON) provider.
You asked the Plan to pay for [lab tests. You say that you would like this claim reprocessed and approved for
payment. The Plan denied your request. The Plan says no prior authorization was obtained 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 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 lab tests provided on November 1, 2019 by an out
of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider at the innetwork
rate.
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 available from network providers at the in-network rate.
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 50% of
the Medicare-allowed amount for each out-of-network primary care provider visit for Medicare-covered
services.
The requested provider is not a network provider with the Plan. If you choose to receive services with this
provider, you will be asked to pay 50% of the Medicare-allowed amount for these services. These services fall
within each out-of-network primary care provider visit for Medicare-covered services benefit category. This
means that you will be 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. The Plan has network providers
from which you may receive services at the in-network rate. Therefore, we decided that the Plan does not have
to pre-approve a referral to an out-of-network provider at the in-network rate.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tier exception for Kevzara (J3590) for the enrollee.You asked the Plan to pre-approve the tier exception. You say that this is medically necessary.The Plan denied your request. The Plan says tier exceptions are not available for very high cost drugs on a specialty tier.The Plan must follow Medicare rules. Medicare rules say that tier exceptions are only available for Part D drugs.The requested drug is covered under Part B. Based on this information, we decided that Medicare rules for coverage of the tier exception have not been met.Therefore, we decided that the Plan does not have to pre-approve a tier exception for Kevzara (J3590) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay fora cystourethroscopy (52332) and urography (74420) provided on September 24, 2019.You asked the Plan to pay fora cystourethroscopy and urography. You say that this should be reprocessed.The Plan denied your request. The Plan says these codes are not supported.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 52332 is cystourethroscopy, with insertion of indwelling ureteral stent (eg, Gibbons or double-J type) and 74420 is urography, retrograde, with or without KUB.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 a cystourethroscopy and urography. Our reviewer says that CPT codes 52332 and 74420 are not supported by the records. Our physician reviewer found while the documentation lists a cystoscopy as having been performed, this is not described, and though the documentation notes that a stent was left in place, the placement is not described. The provision of retrograde urography is nether listed nor described.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a cystourethroscopy and urography have not been met.Therefore, we decided that the Plan does not have to pay fora cystourethroscopy (52332) and urography (74420) provided on September 24, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a kyphoplasty procedure.
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 medically necessary.
The Plan must follow Medicare rules. Medicare rules say that kyphoplasty is not covered for vertebral compression fractures. 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the submitted records show that you have degenerative joint disease (DJD) and a sacral alar fracture. The requested kyphoplasty is considered experimental/investigational in nature for vertebral compression fractures. The services are therefore not reasonable or medically necessary 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a kyphoplasty procedure.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound provided on October 31, 2019.
You asked the Plan to waive the copayment for the ultrasound. You say that you went in for an abdominal aortic aneurysm screening. You say that the doctor didn't order another ultrasound. The Plan denied your request. The Plan says the copayment 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 $325 per day for Medicare-covered diagnostic radiology services. You have been asked to pay $136.44, which is less than the standard $325 copayment for the ultrasound. The ultrasound falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The records show that you did not meet the criteria for the screening, therefore the ultrasound is considered diagnostic. 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 ultrasound provided on October 31, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued SNF services for enrollee.You asked the Plan to pre-approve continued services. You say that the enrollee would be safest in her current location.The Plan denied your request. The Plan says the enrollee does not require daily skilled therapy services.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 continued services. Our physician reviewer found that the enrollee's current level of function is at standby assist with feeding, contact guard assist with grooming/hygiene, moderate assist with upper body dressing, and total assist with bathing, lower body dressing, toileting, toilet transfers, tub/shower transfers, and bed/wheelchair/chair transfers. This enrollee does not require skilled nursing or skilled therapy services with the specialized skill, knowledge and judgment of a to safely and effectively provide medically necessary and reasonable treatment beyond March 30, 2020. The enrollee does not have complex wound care. The skilled nursing or skilled therapy services (or a combination of these services) are not needed on a daily basis in a SNF beyond the dates in question. As a practical matter this enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services for enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that the enrollee needs to regain strength. The Plan denied your request. The Plan says the enrollee does not need an intensive team of providers for care.
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 physician reviewer found that the enrollee slipped while ambulating, and sustained multiple lumbar compression fractures. The hospital course has included pain management. The complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee is at maximal assist for transfers and activities of daily living. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 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 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the Inogen One G4 System Freedom #3 portable oxygen system purchased on June 4, 2019. You asked the Plan to reimburse you for the portable oxygen concentrator. You say that the in-network portable tanks are bulky, weigh a lot, and don't allow you to function normally. The Plan denied your request. The Plan says you did not request prior authorization for the out-of-network purchase. 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 reimburse you for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. Medicare rules say that only rented oxygen equipment is eligible for coverage. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the item at issue in this appeal. The Plan did not pre-approve the item at issue. Purchased oxygen equipment is statutorily non-covered by Medicare. We found no exception that would require the Plan to reimburse you for this item. Therefore, we decided that the Plan does not have to reimburse you for the Inogen One G4 System Freedom #3 portable oxygen system purchased on June 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pacemaker for the enrollee.
You asked the Plan to pre-approve a pacemaker. The Plan denied your request. The Plan says the enrollee does
not have a slow heart rate.
The Plan follows Medicare rules. Medicare rules say that cardiac pacemakers are only covered under certain
medical indications.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve a pacemaker. Our physician reviewer
found that the enrollee has chronic atrial fibrillation with adequate rate control (HR < 110) while compliant
with medications. In addition, there is no documented allergic reaction to rate control medications and no
documented significant intolerance. Lenient rate control has been shown to be non-inferior compared to more
aggressive rate control. Therefore, the documentation does not support inadequate rate control and the medical
necessity for pacemaker placement followed by AV junction ablation 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 a pacemaker have not been met. Therefore, we decided that the Plan does not
have to pre-approve a pacemaker for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the acupuncture services you received from November 20, 2019, to December 9, 2019.
You asked the Plan to pay for the acupuncture services. You say that you cannot afford this bill. The Plan denied your request. The Plan says acupuncture services are not covered.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. The services at issue in this appeal are acupuncture services. Therefore, we decided that the Plan does not have to pay for the acupuncture services you received from November 20, 2019, to December 9, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional $50 for your monthly over-the-counter (OTC) benefit.
You asked the Plan to pre-approve an additional $50 for your monthly OTC benefit. You say that you require additional money for your incontinence supplies. The Plan denied your request. The Plan says that the OTC allowance is a fixed benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items. However, the Plan offers an OTC benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers up to a $100 allowance for OTC items every month. We looked at the file and Medicare rules. There is no provision in the contract which would require the plan to approve more than the $100 monthly allowance. Therefore, we decided that the Plan does not have to pre-approve an additional $50 for your monthly over-the-counter (OTC) benefit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Freestyle Lite test strips for the enrollee.
You asked the Plan to pre-approve these services. The Plan denied your request. The Plan says that no information regarding use of or inability to use the preferred test strips was received.
The Plan must follow Medicare rules. Medicare rules say that plans may limit enrollees to preferred providers. The items at issue are Freestyle Lite test strips. Freestyle is not a preferred provider with the Plan for diabetic supplies. OneTouch and ACCU-CHECK are the preferred providers. Therefore, we decided that the Plan does not have to pre-approve Freestyle Lite test strips for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zioptan eye drops (J3490).
You asked the Plan to pre-approve the Zioptan drops. You say that Zioptan is medically necessary. The Plan
denied your request. The Plan says coverage for this medication is not available under the Part B medical
benefit.
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 Zioptan eye drops (J3490).
Benefits for the Zioptan drops 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on July 8, 2019.You asked the Plan to waive the copayment fora specialist visit. You say that the enrollee met the out-of-pocket maximum amount of $5,800.The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is 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). The enrollee's contract with the Plan says that the MOOP amount for 2019 is $5,800. The enrollee's contract with the Plan also clearly says that enrollees must pay a $45 copayment for specialist services. The enrollee had a specialist visit on July 8, 2019. The record shows the enrollee had only paid $5,513.30 toward the $5,800 MOOP amount for 2019. Therefore, the enrollee is responsible to pay the $45 copayment. The enrollee has been asked to pay a $45 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan.Therefore, we decided that the Plan does not have to waive the copayment fora specialist visit provided on July 8, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the gum surgery and the bone graft for tooth # 3 provided on October 7, 2019.You asked the Plan to reimburse you for the dental services. You say that your bill for the services was over $1,800. You say that you understand that some of the services were dental in nature. You also say that you only expect to be reimbursed for the medical part of this visit for the 2 services.The Plan denied your request. The Plan says the gum surgery and bone graft are dental in nature. The Plan also says that routine dental care is not covered by your medical plan.Medicare generally does not cover dental services. The Plan follows the same rule.The services you are asking the Plan to reimburse you for 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 reimburse you forthe gum surgery and the bone graft for tooth # 3 provided on October 7, 2019.