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

We decided that the Plan does not have to pay forthe medical services provided on October 2, 2019 by an out of network (OON) provider.You asked the Plan to pay foreyewear. You say that your insurance has always covered your eyewear lenses.The Plan denied your request. The Plan says the denial of payment for these items is correct, because this provider is out-of-network with the Plan and you could have obtainedeyewear from an in-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. Your benefits as a member of the Harbor plan do not include supplemental benefits for eyeglasses beyond Medicare's coverage. 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 medical services provided on October 2, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe Omnipod dash 5 pack for the enrollee.You asked the Plan to pre-approve the Omnipod dash 5 pack. You say that this is medically necessary.The Plan denied your request. The Plan says drug coverage for the member is limited to Medicare Part B covered drugs.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 the Omnipod dash 5 pack for the enrollee.Benefits for the Omnipod dash 5 pack 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for physical therapy provided from August 7, 2019 through September 17, 2019.You asked the Plan to waive the copayments forphysical therapy. You say that you were informed you would have no copayment. You say that you cannot afford the bill.The Plan denied your request. The Plan says the copayments 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 a $40 copayment for physical therapy at an in-network outpatient hospital.You have been asked to pay a $40 copayment for each physical therapy visit. The total amount you owe is $480 ($40/visit x 12 visits -$480). Physical therapy fallswithin the "Outpatient rehabilitation services" 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 copayments forphysical therapy provided from August 7, 2019 through September 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea shower chair.You asked the Plan to pre-approvea shower chair. You say that you need a shower chair because you have a balance problem and have fallen.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.Therefore, we decided that the Plan does not have to pre-approvea shower chair.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says the enrollee's current medication is still appropriate.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 to pre-approve Prolia. Our reviewer says that Prolia is not medically reasonable and necessary. Our physician reviewer found that the enrollee has a history of osteoporosis. According to documentation, the enrollee was experiencing ongoing dental conditions and the provider noted "will try switching to Prolia..." There are no further details regarding dental conditions. Without the support of the documentation, there is not adequate rationale to support the use of Prolia as outlined in compendia.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met.Therefore, we decided that the Plan does not have to pre-approveProlia
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.You asked the Plan to pay for the ambulance services. You say that you had fallen on the floor and could not get up. You had to call 911 for assistance and you believe it was an emergency. You say that you had no choice but to call for help.The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on July 6, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare northe Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay forthe ambulance services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea pneumatic compression device (E0652) and segmental pneumatic appliance (E0667).You asked the Plan to pre-approvea pneumatic compression device and sleeve. You say that the medical records provided support the necessity of the services in dispute.The Plan denied your request. The Plan says the enrollee has not had the required four week trial of E0650 or E0651. Therefore, E0667 is non-covered  when requested in  conjunction  with the non-approved  code E0652. 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 an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.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, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.Therefore, we decided that the Plan does not have to pre-approvea pneumatic compression device (E0652) and segmental pneumatic appliance (E0667).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve VenaSeal treatment.You asked the Plan to pre-approve the VenaSeal treatment. The Plan denied your request. The Plan says he health plan does not provide coverage for out-of-network services except for emergent or urgently needed services.Medicare rules say thatplans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the VenaSeal treatment.We found no exception that would require the Plan to pre-approve the VenaSeal treatment.Therefore, we decided that the Plan does not have to pre-approve VenaSeal treatment.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecustom foot orthotics.You asked the Plan to pre-approvethe orthotics. You say that you need these orthotics because your arches are lower than usual.The Plan denied your request. The Plan says you do not have a diagnosis of diabetes and these orthotics are not part of an integral brace. The Plan must follow Medicare rules. Medicare rules say that shoes, inserts, and modifications are covered in limited circumstances. They are covered in selected beneficiaries with diabetes for the prevention or treatment of diabetic foot ulcers. Inserts and other shoe modifications are covered if they are on a shoe that is an integral part of a covered brace and if they are medically necessary for the proper functioning of the brace.We looked at the file and Medicare rules. In this instance, you do not have a documented covered diagnosis of diabetes or diabetic foot ulcers, and these orthotics are not part ofan integral brace. Based on this information, we decided that Medicare rules for coverage of the orthotics have not been met.Therefore, we decided that the Plan does not have to pre-approvecustom foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea power mobility device.You asked the Plan to pre-approvea power mobility device. You say that you have knee implants and arthritis and you cannot walk well. The Plan denied your request. The Plan says criteria for a power mobility device have not been met.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 does not show that you have a mobility deficit that impairs your participation in MRADLs, your condition cannot be improved by a walker, cane or manual wheelchair, or that you can safely operatethe PMD being requested. There is no home assessment documentation. This means that Medicare rules for coverage of a PMD have not been met.Therefore, we decided that the Plan does not have to pre-approvea power mobility device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea MyoPro Motion-G (L8702).You asked the Plan to pre-approvethe MyoPro Motion-G. You say that the orthosis is medically necessary.The Plan denied your request. The Plan says coverage criteria has not been met.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the MyoPro Motion-G. Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found review of documentation does not include a detailed physical examination, history or treatment approach, and discussion of the requested orthosis. Review of literature considers this orthosis investigational and support of its use is not clearly supported in the literature for individuals with weakness related to a cerebrovascular accident.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 MyoPro Motion-G have not been met.Therefore, we decided that the Plan does not have to pre-approvea MyoPro Motion-G (L8702).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora blood draw off a venous access device provided on May 14, 2019.You asked the Plan to waive the copayment fora blood draw off a venous access device. You say that you disagree with the treatment room charges because you only received laboratory services.The Plan denied your request. The Plan says the claims were processed correctly and you are 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). Your contract with the Plan clearly says that you must pay a$300 copayment for each outpatient surgery service. You received a blood draw off a venous access device on May 14, 2019. A blood draw off a venous access device is considered an outpatient surgical procedure. Therefore, you are responsible to pay the allowed amount of $230.28, which is less than the $300 copayment. You have been asked to pay $230.28 for a blood draw off a venous access device. A blood draw off a venous access device falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 fora blood draw off a venous access device provided on May 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for these services hospital discharge day management (99239) provided on April 14, 2019.You asked the Plan to pay for these serviceshospital discharge day management. You say that this claim was improperly denied.The Plan denied your request. The Plan says this code is not supported in the medical records.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 99239 is hospital discharge day management; more than 30 minutes.We find that CPT code 99239 is not supported in the medical record. Specifically, the records do not contain documentation of 31 minutes or more spent on discharge day services. Based on this information, we decided that Medicare rules for coverage of hospital discharge day management have not been met.Therefore, we decided that the Plan does not have to pay for these serviceshospital discharge day management (99239) provided on April 14, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit provided on July 3, 2019 by an out of network (OON) provider.You asked the Plan to pay fora domiciliary or rest home visit. You say that these services were medically necessary.The Plan denied your request. The Plan says these services were not authorized.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 forthe domiciliary or rest home visit provided on July 3, 2019 by an out of network (OON) provider
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the physical therapy visits provided from September 5, 2019 to October 18, 2019.
You asked the Plan to waive the copayments for the physical therapy visits. You say that the provider told you the services would be completely covered. 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 $40 copayment for each therapy visit. You have been asked to pay a $40 copayment for each of the physical therapy visits. ($40 x 13 visits = $520). The physical therapy visits fall within the "Outpatient rehabilitation services" 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 copayments for the physical therapy visits provided from September 5, 2019 to October 18, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approveout-of-area cardiac rehabilitation services.You asked the Plan to pre-approveout-of-area cardiac rehabilitation services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services are not medically necessary.Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve out-of-area cardiac rehabilitation services. Our reviewer says that the documentation does not support that the requested services are urgent or emergent. Our physician reviewer found you have a history coronary artery disease including stent placement. Post stent cardiac rehabilitation is usual and standard care that is medically appropriate in this circumstance. While these services are most appropriate when initiated soon after coronary stent placement, there would be little difference in benefit if you were to initiate cardiac rehab now in the out-of-network facility versus waiting until March 2020 when you return to the service area. Therefore, you do not meet criteria for the requested out-of-area services.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of out-of-area cardiac rehabilitation services have not been met.Therefore, we decided that the Plan does not have to pre-approveout-of-area cardiac rehabilitation services.
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 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 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 correctin 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 based on review of the available records, the enrollee does not meet criteria for IRF admission. The enrollee was medically stable with no evidence of need for supervision by a physical medicine and rehabilitation (PMR) Physician or needs acute rehab nursing care. They may benefit from further physical therapy (PT) and occupational therapy (OT) but does not require or tolerate an intensive therapy program. IRF admission is not medically necessary based on their current functional status, poor activity tolerance and medical stability.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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprovea pneumatic compression device (E0652).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 basic pump 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 an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. 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, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by atechnician who is skilled in and who regularly and successfully uses the appliance provided.Therefore, we decided that the Plan does not have to preapprovea pneumatic compression device (E0652).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code S8420-S8429.You asked the Plan to pre-approve the compression stockings. You say that the enrollee requires the compression garments.The Plan denied your request. The Plan says the compression stockings are noncovered.The Plan must follow Medicare rules. The rules say that compression stockings described by code S8420-S8429 are noncovered. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan.Therefore, we decided that the Plan does not have to pre-approvecompression stockings identified with code S8420-S8429.