Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe resin-based composite -one surface, posterior, resin-based composite -two surfaces, posterior, and resin-based composite -three surfaces, posterior on August 27, 2019.You asked the Plan to pay forthe resin-based composites. You say that when you found out that you had a PPO plan you thought you could go back to your old dentist.The Plan denied your request. The Plan says you are responsible for 100% of the services because there is no coverage for services provided by an out-of-network provider.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 covered under this benefit when they are received out-of-network. Your contract clearly states that there is a 100% coinsurance for resin-based composites when the services are received out-of-network. The record shows that you saw an out-of-network provider, so the Plan is not obligated to pay the in-network benefit rates for the resin-based composites.Therefore, we decided that the Plan does not have to pay forthe resin-based composite -one surface, posterior, resin-based composite -two surfaces, posterior, and resin-based composite -three surfaces, posterior on August 27, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on
April 9, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your
request. The Plan says the documentation does not indicate services are necessary for treatment of the
enrollee's condition.
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 following the noncovered visit are
likewise noncovered. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis
(L0650) provided to the enrollee on April 9, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe inpatient hospital stay provided from August 9, 2019 to August 21, 2019.You asked the Plan to waive the copayment forthe inpatient hospital stay. You say that you should not have a pay another copayment because you were transferred to a second hospital. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $360 copayment per day for days 1-5 for in-network covered hospital care. Thereafter, you pay a $0 copayment for additional Medicare-covered days during your hospital admission. You have been asked to pay a $360 copayment for each day for days 1-5 of the inpatient hospital stay. ($360 x 5 = $1,800). The inpatient hospital stay falls within the "Inpatient hospital care" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment foran inpatient hospital stay provided by "the hospital" from August 9, 2019 to August 21, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the oxygen concentrator provided on August 25, 2019 by out
of network provider.
You asked the Plan to pay for the oxygen concentrator. You say that the enrollee wants to continue to receive
services from the provider. The Plan denied your request. The Plan says you did not have prior
authorization for the oxygen concentrator and there is not physician order.
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 oxygen concentrator provided on August 25,
2019 by out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lumbar-sacral orthosis provided on March 13, 2019.You asked the Plan to pay forthe lumbar-sacral orthosis (L0650). You say that the orthosis was medically necessary.The Plan denied your request. The Plan says rules for telehealth services have not been met.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 presentedfrom 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 following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay forthe lumbar-sacral orthosis provided on March 13, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not have to pre-approvethe diabetic footwear to be provided.You asked the Plan to pre-approvethe diabetic shoes and custom inserts from an out-of-network provider. You say that the enrollee is home bound and you have a mobile laboratory.The Plan denied your request. The Plan says the record does not show the enrollee is home bound and there are in-network providers that can provide the orthotics.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 items/services at issue in this appeal. The record shows the enrollee was in your office on October 11, 2019and physician office on November 20, 2019. 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-approvethe diabetic footwear to be provided..
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea vacuum erection device.You asked the Plan to pre-approvea Male Vacuum Erection System (L7900). You say that because of a surgery the enrollee needs a vacuum erection device.The Plan denied your request. The Plan says vacuum erection devices are not covered by Medicare or the Plan.The Plan must follow Medicare rules. Medicare rules say that vacuum erection devices are statutorily non-covered.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Male Vacuum Erection System (L7900) have not been met.Therefore, we decided that the Plan does not have to pre-approvea vacuum erection device
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe medical services to be provided by out of network provider, "the provider".You asked the Plan to pre-approvespecialist services. You say that you feel like the Plan is doing nothing to help you with back and leg pain.The Plan denied your request. The Plan says there are in-network providers available.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 incases 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. 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-approvethe medical services to be provided by out of network provider, "the provider".
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay fornon-emergency ambulance transport (A0428) and ground mileage (A0425) provided on August 16, 2019 by "the provider".You asked the Plan to pay fornon-emergency ambulance transport and ground mileage. You say that the enrollee was not enrolled in hospice at the time of service.The Plan denied your request. The Plan says based on Medicare billing criteria, Medicare fee-for-service retains payment responsibility for all hospice and non-hospice related claims beginning on the date of the hospice election.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay fornon-emergency ambulance transport (A0428) and ground mileage (A0425) provided on August 16, 2019 by "the provider".
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea resin-based composite and porcelain crowns for tooth #'s 4, 12, and 13.You asked the Plan to pre-approvethe resin-based composite and porcelain crowns. You say that you have been going to this provider forever.The Plan denied your request. The Plan says the provider requested for these services is not an in-network provider. The Plan also says that services done by an out-of-network dentist are not covered.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 covered when they are received out-of-network.Therefore, we decided that the Plan does not have to pre-approvea resin-based composite and porcelain crowns for tooth #'s 4, 12, and 13.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe wheelchair ramp.You asked the Plan to pre-approvethe wheelchair ramp. You say that you feel that this is medically necessary for the enrollee.The Plan denied your request. The Plan says this item is considered a convenience item and not primarily medical in nature and not covered.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-approvethe wheelchair ramp.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe glucose monitor, test strips, lancets, control solution, and lancet device provided from May 31, 2019 to August 19, 2019.
You asked the Plan to pay forthe glucose monitor (E0607), test strips (A4253), lancets (A4259), control solution (A4256), and lancet device (A4258). You say that the Plan should pay this claim.The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket does not have thetracking number on it and the Proof of Delivery does not have a description of the items delivered.Therefore, we decided that the Plan does not have to pay forthe glucose monitor, test strips, lancets, control solution, and lancet device provided from May 31, 2019 to August 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endodontic.
You asked the Plan to pre-approve the endodontic therapy. You say that you really need this root canal because you are in pain. The Plan denied your request. The Plan says this service is not covered under your benefit package.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve endodontic.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to providenon-emergent transportation for an office visit.You asked the Plan to providenon-emergent stretcher transportation. You say that because of medical conditions the enrollee requires stretcher transportation for visits. The Plan denied your request. The Plan says a physician's office is not a covered destination.The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when they meet certain origin and destination requirements. A doctor's office is not a covered destination. The services you have asked the Plan to provide are ambulance transport services to a doctor's office.Therefore, we decided that the Plan does not have to providenon-emergent transportation for an office visit.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services to be provided by "the doctor". You asked the Plan to pre-approve the physician's 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 outof the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the planMedicare 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 physician's services to be provided by "the doctor".
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe eye exam, and the ophthalmic biometry provided on December 17, 2018 by the out of network provider.You asked the Plan to pay forthe vision care services. You say that your primary care physician referred you for the services.The Plan denied your request. The Plan says authorization was not obtained before you received 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 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 forthe eye exam, and the ophthalmic biometry provided on December 17, 2018 by the out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a back-up battery for a continuous positive airway device.
You asked the Plan to pre-approve a back-up battery. You say that you have been unable to sleep for 3 days due to power shutting off which is happening often and you need the backup battery so you can have a quality of life. The Plan denied your request. The Plan says this item is a convenience item and not a covered DME item.
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 a back-up battery for a continuous positive airway device.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services.You asked the Plan to pre-approveSNF services. You say that you are unsteady on your feet, and are afraid of falling.The Plan denied your request. The Plan says there is no indication that you require a SNF for 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 pre-approve SNF services. Our physician reviewer found that your current level of function is modified independent with supine to sit and sit to stand, standby assist with bed to chair transfer, ambulating 150 feet with standby assist, modified independent with grooming and lower body dressing, supervision with upper body dressing and toileting. There are no noted daily skilled complex nursing needs. You are ambulating household distances and requires little assistance with mobility and transfers. While you may benefit from continuing physical and occupational therapy, the records do not support the need for daily therapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power operated vehicle.
You asked the Plan to pre-approve a scooter (K0800). You say that you want a scooter because yours was stolen. The Plan denied your request. The Plan says you were approved for a power wheelchair (K0823) that was recommended per your evaluation.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The file shows that a power wheelchair was the most appropriate mobility device for you and was approved. Therefore, we decided that the Plan does not have to pre-approve a scooter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvefoot orthotics.You asked the Plan to pre-approvefoot orthotics. You say that you cannot get shoes off the rack that will fit because of your foot condition.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 you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition.Therefore, we decided that the Plan does not have to pre-approvefoot orthotics
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe medical services.You asked the Plan to pre-approvespecialist office visit. You say that your primary doctor referred you to an out of network provider because of the specific skill set that they have.The Plan denied your request. The Plan says there are in-network providers available.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 at the clinic 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-approvethe medical services
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea portable oxygen concentrator.You asked the Plan to pre-approvea portable oxygen concentrator. You say that you are unable to go anywhere or leave your home because of the weight of your portable tanks.The Plan denied your request. The Plan says you have portable oxygen tanks that meetyour in-home oxygen needs and are under five years old.The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary.The record shows that you have anoxygen system with refillable portable tanks. This oxygen system with refillable portable tanks meets your in-home needs and serves the same purpose as a portable oxygen concentrator.Therefore, we decided that the Plan does not have to pre-approvea portable oxygen concentrator.