Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the annual wellness visit and office visit services provided on May 8, 2019 by the out of network provider.
You asked the Plan to pay for the annual wellness visit and office visit services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received are not a covered benefit when provided by an out-of-network provider.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the annual wellness visit and office visit services provided on May 8, 2019 by the out of network provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient hospital behavioral health services provided on September 24, 2019.You asked the Plan to pay for the outpatienthospital behavioral health services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the servicesat 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 outpatient hospital behavioral health services provided on September 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
You asked the Plan to pre-approve a CGM. The Plan denied your request. The Plan says that this is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered when the above criteria have been met. We looked at the file and Medicare rules. The file indicates you are not treated by insulin injections three or more times a day or testing your blood glucose four or more times a day. Based on this information, we decided that Medicare rules for coverage of a CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to lower the copayment for three physical therapy visits (97116, 97110, 97112) provided from June 25, 2019 to June 27, 2019.
You asked the Plan to lower the copayment for three physical therapy visits. You say that these services should have a $10 copayment. The Plan denied your request. The Plan says that these services processed correctly
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that enrollees must pay a $10 copayment for physical therapy services provided in a specialist's office or a comprehensive outpatient rehabilitation facility, and a $40 copayment in an outpatient hospital. The Plan says you must pay $40 copayment for each of these physical therapy visits. However, these services were billed with a place of service code of 62 for a comprehensive outpatient rehabilitation facility. Based on the Plan contract, you cannot be asked to pay more than $10 copayment for each physical therapy visit provided in comprehensive outpatient rehabilitation facility. Therefore, we decided that the Plan has to lower the copayment for three physical therapy visits (97116, 97110, 97112) provided from June 25, 2019 to June 27, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services rendered to the enrollee on January 24, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not eligible for payment.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered followingthe noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay forthe laboratory services rendered to the enrollee on January 24, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the frames purchased on December 11, 2019.
You asked the Plan to pre-approve the frames. You say that your eye sight has changed since your stroke and
you can hardly see with the glasses. The Plan denied your request. The Plan says the benefit limit has been
reached.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan covers these services one routine eye exam every year and up to $250 for contact lenses
every 2 years.
We looked at the file and the Plan's rules. Vision benefit for eyeglass frames is available once every 2 years.
Records show that you received lenses and frames on December 12, 2018. The benefit is not available until
December 1, 2020. Based on this information, we decided that the Plan's rules for coverage of the frames have
not been met. Therefore, we decided that the Plan does not have to pre-approve the frames purchased on
December 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on
September 6, 2019.
You asked the Plan to pay for the laboratory services. You say that the laboratory testing was medically
necessary. The Plan denied your request. The Plan says their onsite inspection of the property, at your
certificate listed place of service, showed no evidence that a laboratory was ever operated there.
The Plan must follow Medicare rules. Medicare rules say that all information must corroborate the
documentation in the record and support that coverage criteria are met.
In this case, the Plan attests that the address listed on this claim is not valid as there is no laboratory operating
at that address. As such, we find that this claim does not corroborate other information in the record and is
correctly denied. Therefore, we decided that the Plan does not have to pay for laboratory services provided  on September 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve L300 Bioness Go Lower System and L300 Bioness Go Thigh Plus System coded as E0770 and E1399.
You asked the Plan to pre-approve L300 Bioness Go Lower System and L300 Bioness Go Thigh Plus System. You say that youhad a trial of this system and it helped you by 50% to walk better. You have had enough of falls and when you have MS any help will result in a better quality of life. The Plan denied your request. The Plan says experimental and investigational devices are not covered.
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 L300 Bioness Go Lower System and L300 Bioness Go Thigh Plus System have not been met. Therefore, we decided that the Plan does not have to pre-approve L300 Bioness Go Lower System and L300 Bioness Go Thigh Plus System coded as E0770 and E1399.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an upper partial denture (D5213), and a lower partial denture (D5214).
You asked the Plan to pre-approve the dental items. You say that you were advised you had an infection in the gum. You also say that you need replacement partial dentures badly. The Plan denied your request. The Plan says the frequency limit for dentures has been reached. The Plan also says that you last received dentures on March 3, 2016.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage and dentures are a covered service, the frequency limit has been reached. Therefore, we decided that the Plan does not have to pre-approve an upper partial denture (D5213), and a lower partial denture (D5214).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acupuncture services.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not covered under any condition.
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 pre-approve acupuncture services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medical services to be provided by an out-of-network provider.
You asked the Plan to pre-approve the services. You say that starting with a new physician would not be in your best interest. The Plan denied your request. The Plan says the services are available in-network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 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 medical services to be provided by an out-of-network provider.
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. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the services are not medically necessary. Our physician reviewer found there is no documentation provided necessitating admission to a LTACH. The enrollee still requires acute level 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 they are 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 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gralise.You asked the Plan to pre-approvethese 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-approveGralise.Benefits for these servicesmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from July 8, 2019 to August 1, 2019.You asked the Plan to payforthe skilled nursing services. You say that the services the enrollee required and received are coverable under the Medicare Act.The Plan denied your request. The Plan says the enrollee's condition did not require daily skilled services at an inpatient skilled nursing facility level of care.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 pay for the skilled nursing services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 the skilled nursing services have not been met.Therefore, we decided that the Plan does not have to pay forthe skilled nursing services provided from July 8, 2019 to August 1, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing rendered to the enrollee on August 27, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 pay forthe drug testing rendered to the enrollee on August 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for behavioral health services provided on July 12, 2019.
You asked the Plan to pay for the behavioral health services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the service 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 behavioral health services provided on July 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to providea Group 3 heavy duty power wheelchair and accessories.You asked the Plan to providea Group 3 heavy duty power wheelchair and accessories. You say that the enrollee has limited mobility due to pain and weakness and needs a Group 3 heavy duty power wheelchair and accessories.The Plan denied your request. The Plan says the documentation provided does not confirm that the enrollee has a mobility limitation due to a neurological condition, myopathy, or congenital skeletal deformity.The Plan must follow Medicarerules. 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 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 providea Group 3 heavy duty power wheelchair and accessories.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a pneumatic compression device (E0650).
You asked the Plan to preapprove a pneumatic compression device. You say that the enrollee requires the device. The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the conservative therapy that Medicare requires.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with conservative therapy that includes regular and compliant use of an appropriate compression bandage system or compression garment to provide adequate graduated compression, adequate compression. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular use of compression garments, elevation, and exercise. Therefore, we decided that the Plan does not have to preapprove a pneumatic compression device (E0650).
Appeal type: Practitioner Services
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 June 27, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network deficiency 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 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 June 27, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the seat lift mechanism of a seat lift chair.
You asked the Plan to pre-approve the seat lift mechanism of a seat lift chair. You say that you sleep in your
recliner and it is worn out so you have difficulty getting out of it. The Plan denied your request. The Plan says
the records do not show severe arthritis of the hip or knee, or a severe neuromuscular disease.
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions
listed above are met. Medicare does not cover the upholstered portion of a seat lift chair.
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the seat lift mechanism of a seat lift chair. have not been met. Therefore, we decided that the Plan
does not have to pre-approve the seat lift mechanism of a seat lift chair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to make an in-network exception for an office visit provided by an out-of-network provider.
You asked the Plan to make an in-network exception for the office visit. You say that after an injury, the member was told to see this provider due to his expertise and you were not aware that this provider is out-of-network until 30 minutes before the appointment. The Plan denied your request. The Plan says there are in-network providers in the region and no Network inadequacies.
The Plan must follow Medicare rules. Medicare rules say that a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information. We looked at the file, Medicare rules and the Plan contract. Based on this information, we decided that the Plan's rules for an in-network exception for the office visit have not been met. Specifically, the Plan contract clearly states that if you use an out-of-network provider, your share of the costs for your covered services may be higher. Therefore, we decided that the Plan does not have to make an in-network exception for an office visit provided by an out-of-network provider.