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

We decided that the Plan does not have to pay for the chiropractic office visit (99203) provided to you on January 27, 2021.

You asked the Plan to pay for the visit. The Plan denied your request. The Plan says this is not a covered benefit.

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 records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the chiropractic office visit (99203) provided to you on January 27, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve seven (7) additional PT visits.

You asked the Plan to pre-approve seven (7) additional PT visits. You say that seven (7) additional PT visits are medically necessary. The Plan denied your request. The Plan says seven (7) additional PT visits are not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 

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 seven (7) additional PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that in this case, you have previously been treated with outpatient therapies and should be independent with a home exercise program. There is no documentation of a recent injury or decline in function. The additional therapy services are not an appropriate duration and frequency for treatment of your medical condition and therefore are not medically necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of seven (7) additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve seven (7) additional PT visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit (99214) provided January 19, 2021.

You asked the Plan to waive the copayment for the office visit. You say that this was a wellness visit and the copayment should be waived. The Plan denied your request. The Plan says a wellness visit was already provided in the past 12 months. The correct copayment was applied to the office visit.

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 $20 copayment for primary care visits. 

You have been asked to pay a $20 copayment for the office visit. The office visit falls within the primary care visits 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 for an office visit (99214) provided January 19, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for medication administration (80053, 36415, 85025, 96367) provided January 6, 2021 to January 27, 2021.

You asked the Plan to waive the coinsurance for the medication administration. You say that the coinsurance should be waived. The Plan denied your request. The Plan says the correct cost-sharing was applied.

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 20% coinsurance for Part B Drugs. 

You have been asked to pay a 20% coinsurance for the medication administration. The medication administration falls within the Part B Drugs 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 coinsurance for medication administration (80053, 36415, 85025, 96367) provided January 6, 2021 to January 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the hearing aids provided on March 17, 2021.

You asked the Plan to pay more for the hearing aids. You say that the hearing aids costs a total of $5,550 but you were only sent coverage for one ear. You say that you should receive another $857.72 for the second ear. The Plan denied your request. The Plan says the maximum allowance towards the hearing aid purchase has been issued and the remaining amount is your responsibility.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan only pays $1,500 towards hearing aids every 36 months. 

We carefully reviewed the case file and applied the relevant Medicare rules to determine if the Plan was correct in denying the request to pay more for the hearing aids. Based on this information, we decided that the Plan's rules for more coverage of the hearing aids have not been met. The Plan paid $1,500 toward the hearing aids provided on March 17, 2021, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay more for the hearing aids provided on March 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that admission to an IRF is medically necessary. The Plan denied your request. The Plan says criteria for admission to an IRF are not met.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that 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 does require physical and occupational therapy, but there is no documented need for an intensive rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Medically necessary services can be provided in a different level of 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the blepharoplasty of the upper eyelid (15823).

You asked the Plan to pre-approve the blepharoplasty of the upper eyelid. You say that this request is medically necessary. The Plan denied your request. The Plan says the criteria for the requested procedure have not been met.

The Plan follows Medicare rules. Medicare rules say that a vision field test must be completed prior to the requested blepharoplasty surgery. 

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 blepharoplasty of the upper eyelid. Our reviewer says that the requested service is not medically reasonable and necessary. Our physician reviewer found that the record indicates that the enrollee has dermatochalasis. The records provided do not include the results of visual field testing as required by the coverage criteria. The coverage criteria have not been met in this case. 

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 blepharoplasty of the upper eyelid have not been met. Therefore, we decided that the Plan does not have to pre-approve the blepharoplasty of the upper eyelid (15823).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a wheelchair van ramp provided on September 25, 2020.

You asked the Plan to pay for a wheelchair van ramp. You say that you were informed by a representative of
the Plan that the Plan would cover the cost of the medically necessary ramp. The Plan denied your request. The
Plan says rules for durable medical equipment have not been met.

The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate
and needed for use inside the home.

The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not
have to pay for a wheelchair van ramp provided on September 25, 2020.

Your complaint about receiving erroneous or incomplete information about your benefits from a representative
of the Plan is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be
answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the inlay - porcelain/ceramic - three or more surfaces
(D2630), core buildup, including any pins when required (D2950) and crown - porcelain/ceramic (D2740)
provided April 26, 2021.

You asked the Plan to pay for the inlay, core buildup and crown. You say that you would like the services
covered. The Plan denied your request. The Plan says these services are not covered under your dental 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 for the inlay - porcelain/ceramic - three or more surfaces (D2630), core buildup, including any pins when required (D2950) and crown - porcelain/ceramic (D2740) provided April 26, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve PT and OT.

You asked the Plan to pre-approve the PT and OT services. You say that you need PT and OT. The Plan denied your request. The Plan says the medical records show that you have met your goals of care, and ongoing care needs are not skilled and are being provided by your caregiver. The Plan also says that no further skilled needs are identified.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.

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 PT and OT services. Our reviewer says that ongoing home health therapy services are not medically necessary or reasonable. Our physician reviewer found you do not have documented therapy needs, having progressed to a level that is appropriate for outpatient therapy, a home exercise program and custodial 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 PT and OT services have not been met. Therefore, we decided that the Plan does not have to pre-approve PT and OT.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the cervical collar, semi-rigid, thermoplastic foam, two piece
with thoracic extension, prefabricated, off-the-shelf (L0174) provided on April 18, 2021 by an out-of-network
(OON) provider.

You asked the Plan to pay for the cervical collar. You say that you are a DME supplier only and are separate
from the hospital. You provide your products to the hospital and are not contracted with the hospital. The Plan
denied your request. The Plan says enrollee's must receive their medical services from an in-network provider
with the exception being urgent or emergent services. Non-emergent services with non-contracted providers
require prior authorization before services being rendered.

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 had network providers
available who could have provided 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 cervical collar, semi-rigid, thermoplastic foam,
two piece with thoracic extension, prefabricated, off-the-shelf (L0174) provided on April 18, 2021 by an outof-
network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not medically necessary. Our physician reviewer found you were admitted to the hospital for weakness, falls, and low blood sodium (hyponatremia). You are now medically stable with no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. You may benefit from further therapy, but you do not require an intensive therapy program in an IRF. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Partially Favorable

We decided that the Plan has to pre-approve lumbar laminectomy. We decided that the Plan does not have to pre-approve spinal fusion and bone marrow aspirate.

You asked the Plan to pre-approve the requested procedures. You say that this is medically necessary, as the enrollee has completed the six weeks of physical therapy as requested on the denial. The Plan says that this is not medically necessary.

We decided that the Plan has to pre-approve lumbar laminectomy.

The Plan follows Medicare rules. Medicare rules say that services are covered when they are medically necessary.

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 for lumbar laminectomy. Our reviewer says that this requested surgery is medically reasonable and necessary. Our physician reviewer found there is moderate stenosis at L3-L4. Therefore, only laminectomy at this level meets the criteria for this surgery. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of lumbar laminectomy have been met. Therefore, we decided that the Plan has to pre-approve lumbar laminectomy.

We also decided that the Plan does not have to pre-approve spinal fusion and bone marrow aspirate.

The Plan follows Medicare rules. Medicare rules say that services are covered when they are medically necessary. 

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 for the remaining procedures. Our reviewer says that spinal fusion is not needed as there is no instability documented. Bone marrow aspiration remains experimental and needs more research to support its use.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of spinal fusion and bone marrow aspirate have not been met. Therefore, we decided that the Plan does not have to pre-approve spinal fusion and bone marrow aspirate.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the periodic oral evaluation (D0120), the intraoral - complete series of radiographic images (D0210), and the prophylaxis (D1110) received November 11, 2020 from the out-of-network provider.

You asked the Plan to pay an additional amount for the dental services. You say that the Plan paid the full amount for these services in 2019. The Plan denied your request. The Plan says providers are paid based on Maximum Allowable Charge (MAC). For services covered under the plan, you may still be billed by an out-of-network provider for any amount greater than the MAC payment made by the plan to the 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 payment is in excess of what is under this benefit. Providers are paid based on Maximum Allowable Charge (MAC). For services covered under the plan, you may still be billed by an out-of-network provider for any amount greater than the MAC payment made by the plan to the provider. The Plan has agreed to pay 100% of the cost up to the MAC for the services received from the out-of-network provider. You are responsible for the difference between the Plan's MAC and what was billed by the out-of-network provider. Therefore, we decided that the Plan does not have to pay an additional amount for the periodic oral evaluation (D0120), the intraoral - complete series of radiographic images (D0210), and the prophylaxis (D1110) received November 11, 2020 from the out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0651) and accessories (E0373) provided on August 11, 2020.

You asked the Plan to pay for a pneumatic compression device and accessories. You say that these items were medically necessary. The Plan denied your request. The Plan says there is not a valid order for these items.

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 does not contain a valid physician order, proof of delivery for the supplies provided in this case. The prescription form in the file does not specify the specific items billed in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0651) and accessories (E0373) provided on August 11, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eszopiclone tablets.

You asked the Plan to pre-approve Eszopiclone tablets. You say that the enrollee has failed other medications. The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug plan.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Eszopiclone tablets.

Benefits for Eszopiclone tablets 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 pay for the continuous positive airway pressure (CPAP) management services provided on February 17, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the OON services. The Plan denied your request. The Plan says out-of-network services were provided without 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided 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 items/services. Therefore, we decided that the Plan does not have to pay for the continuous positive airway pressure (CPAP) management services provided on February 17, 2021 by an out-of-network (OON) provider.