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

We decided that the Plan does not have to pay for a PCD (E0676) provided to the enrollee on January 20, 2020.
You asked the Plan to pay for the PCD. You say that the claim should be paid. The Plan denied your request. The Plan says the pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery. The Plan states the enrollee used the equipment in the facility during and/or after surgery and payment for this service would have been included in the facility DRG payment
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. 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, this item is not a covered benefit of Medicare or the health plan. This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pay for a PCD (E0676) provided to the enrollee on January 20, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the ambulance transport provided on February 3,
2020.
You asked the Plan to waive the copay for the ambulance transport. The Plan denied your request. The Plan
says that the cost-sharing was 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 $250
copay for Medicare-covered ambulance services.
You have been asked to pay a $250 copay for the ambulance transport. The ambulance transport falls within
the Medicare-covered ambulance 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 copay for
the ambulance transport provided on February 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for a recliner lift chair provided on November 2, 2019
by an out of network provider.
You asked the Plan to reimburse you for the seat lift mechanism of a seat lift chair. You say that your chair
broke and there was no repair shop open. The Plan denied your request. The Plan says you did not have prior
authorization for the out-of-network purchase.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to reimburse you for care from out-of-network providers only in cases involving
emergencies, out of area urgent care and pre-approved care.
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 reimburse you for these
items/services. Therefore, we decided that the Plan does not have to reimburse you for a recliner lift chair
provided on November 2, 2019 by an out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electronic connection, expandable controller,
expandable controller harness, power seat elevation feature and functional reach package for the enrollee.
You asked the Plan to pre-approve these services. You say that these items are medically necessary for the
enrollee. The Plan denied your request. The Plan says that the upper limb function is adequate for the member
to be able to control the power options using their own switches.
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature is non-covered
because it is not primarily medical in nature. The file indicates that the functional reach package is attached to
the power seat elevation feature. Therefore, we decided that the Plan does not have to pre-approve a power seat
elevation feature or functional reach package for the enrollee.
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 these services. Our reviewer says that
the electronic connection, expandable controller and expandable controller harness are not considered
medically reasonable and necessary in this case. The documentation does not indicate that the patient requires a
proportional input device (e.g., mini, compact, or short throw joysticks, touchpads, chin control, head control,
etc.) other than a standard proportional joystick, a non-proportional input device (e.g., sip and puff, head array,
etc.). The patient does not need to operate 3 or more powered seating actuators through the drive control. The
patient does not need an expandable controller to be able to operate one or more of the following: a separate
display (i.e., for alternate control devices); other electronic devices (e.g., control of an augmentative speech
device or computer through the chair's drive control) or an attendant control. The documentation indicates the
patient has sufficient function to be able to be independent with upper body bathing, dressing, self-feeding,
hygiene and operating a wheelchair with a standard joystick, therefore, she should be able to control the power
features through their own individual switches. Our physician reviewer found that the enrollee's condition does
not meet criteria for coverage of an electronic connection, expandable controller and expandable controller
harness.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve an electronic connection, expandable controller and expandable controller harness for the
enrollee.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to waive the deductible for an endoscopy provided on January 7, 2020.
You asked the Plan to waive the deductible for an endoscopy. You say that you disagree with the charges. The
Plan denied your request. The Plan says that 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 does not say in clear and accurate
which physician/practitioner services, including doctor's office visits are subject to deductible charges.
We looked at your contract with the Plan. We did not see where the contract says enrollees must pay a $187.64
deductible for endoscopy services provided by a physician/practitioner. The Plan contract does not clearly say
which physician/practitioner services are subject to deductible charges. This means that the Plan did not follow
Medicare rules for disclosure of cost sharing information. Therefore, we decided that the Plan has to waive the
deductible for an endoscopy provided on January 7, 2020.
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 for the two extractions provided on January 14, 2020 by an
OON provider.
You asked the Plan to pay for the extractions. You say that you were told that the treating provider was innetwork
with your plan and you would like the services to be covered at the in-network rate. The Plan denied
your request. The Plan says the treating provider is OON with your Plan and the claim processed correctly. The
Plan also says that they confirmed there was no call from you regarding this provider's participation status prior
to the services being rendered.
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, you are responsible for the difference
between the Plan's payment to you and the amount charged by the nonparticipating dentist. The Plan confirmed
with the provider that you were not told that this provider participated with your specific dental plan.
Therefore, we decided that the Plan does not have to pay for the two extractions provided on January 14, 2020
by an OON provider.
Appeal type: ER
Decision: Favorable

We decided that the Plan has to waive the copayment for the emergency room visit provided on January 11,
2020.
You asked the Plan to waive the copayment for the emergency room visit. You say that you went to an urgent
care center and did not go to an emergency room. You say you should have a $5 copayment. The Plan denied
your request. The Plan says that you have been charged the correct cost sharing amount.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. There were no medical records submitted from the in-network provider to show
whether the visit was provided at an emergency room or an urgent care center. Therefore, we decided that the
Plan has to waive the copayment for the emergency room visit provided on January 11, 2020.
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 for the dental services provided on February 10, 2020 by a non-participating provider.
You asked the Plan to pay for the dental services. You say that you were advised this provider is participating. The Plan denied your request. The Plan says the provider does not participate with the supplemental dental plan.
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. The provider does not participate with the supplemental dental plan. Your EOC states, services performed by a non-participating dentist will not be covered. Therefore, we decided that the Plan does not have to pay for the dental services provided on February 10, 2020 by a non-participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve low vision therapy.
You asked the Plan to pre-approve the low vision therapy. You say that you would like reconsideration because
you were told that low vision therapy would help your vision. The Plan denied your request. The Plan says
your requested provider is not in-network with the Plan.
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and
eyewear.
The services you asked the Plan to pre-approve are considered routine vision services or eyewear. Low vision
therapy is not a covered benefit under Medicare or the Plan. Therefore, we decided that the Plan does not have
to pre-approve low vision therapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Trilogy non-invasive home ventilator (E0466).
You asked the Plan to pre-approve the non-invasive home ventilator. You say that the records provided should
support the necessity of the service in dispute. The Plan denied your request. The Plan says the records do not
support medical necessity of the requested service.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory
failure due to COPD.
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 non-invasive home ventilator. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found the enrollee has COPD, but there is no documentation of increased CO2 on
an arterial blood gas obtained when the enrollee is in a stable state (the blood gas results in the medical record
are venous, obtained while the enrollee was hospitalized). The order is for the ventilator on AVAPS-AE mode,
which can be provided with certain BiPAP devices. Medicare does not cover a home ventilator when used as
BiPAP. There is no evidence of BiPAP failure. Coverage criteria for a home ventilator are not met.
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 non-invasive home ventilator have not been met. Therefore, we decided that
the Plan does not have to pre-approve Trilogy non-invasive home ventilator (E0466).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for hearing aids provided on May 10, 2019.
You asked the Plan to reimburse you for the hearing aids. 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 out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to reimburse you for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the hearing aids. We found no exception that would require the Plan to reimburse you for these items. Therefore, we decided that the Plan does not have to reimburse you for hearing aids provided on May 10, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on September 3, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says there is evidence of misrepresented services.
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 88189 is "Flow cytometry, interpretation; 16 or more
markers."
We find that CPT code 88189 is not supported in the medical record. Specifically, the services cannot be
confirmed to have been rendered at the address that the provider claims they were rendered at. It appears that
there is no laboratory at the location provided. CPT 88189 cannot be confirmed. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on
September 3, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mandibular partial denture (D5226).
You asked the Plan to pre-approve the mandibular partial denture. The Plan denied your request. The Plan says this procedure is not listed as covered by your plan.
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 a mandibular partial denture (D5226).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for services provided on January 14, 2020.
You asked the Plan to pay for the ambulance services. You say that the ambulance service was medically
necessary. The Plan denied your request. The Plan says a manifestation code should not be billed as the only
code, first code, or primary code on the claim.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate ICD-10 code.
Specifically L99 is a manifestation code and cannot be used as a diagnosis code on the claim. Based on this
information, we decided that Medicare rules for coverage of the ambulance services have not been met.
Therefore, we decided that the Plan does not have to pay for services provided by on January 14, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa.
You asked the Plan to pre-approve Euflexxa. The Plan denied your request. The Plan says the enrollee has not
had previous treatment, contraindication, or intolerance to Orthovisc and Monovisc.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.
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 Euflexxa. Our physician reviewer found
that the Plan's step therapy criteria require trial of Orthovisc and Monovisc prior to approval of the requested
drug. The documentation submitted indicates that the enrollee has not had prior treatment, contraindication, or
intolerance to the required alternatives Orthovisc and Monovisc. The documentation does not state why the
alternatives required by the Plan would not be as effective for the enrollee, or would have adverse effects for
the enrollee. Therefore, the requested drug is not medically reasonable or 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have
to pre-approve Euflexxa.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.
You asked the Plan to pre-approve incontinence supplies. You say that you are appealing. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on October 1, 2019, October 11, 2019 and October 28, 2019.
You asked the Plan to pay for the dental services. You say that you feel the denial is incorrect because of your repeated infusions of Tecentriq for bladder cancer. You also say that after receiving the entire course of treatments did you suffer a complete breakdown of your dental health. The Plan denied your request. The Plan says the services provided appear to be primarily dental in nature and therefore do not meet criteria to be covered under your medical benefits. The Plan also says that you have exceeded the $200 maximum dental benefit for your plan.
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 Plan offers a $200 annual dental benefit maximum. The contract says that you will be responsible for any cost above the $200. The record shows that you met the annual maximum benefit on June 4, 2019 and your annual maximum benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the dental services provided on October 1, 2019, October 11, 2019 and October 28, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from September 11,
2019 to October 10, 2019.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee's
condition no longer required daily skilled services at an inpatient skilled nursing facility (SNF) 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 the enrollee did not meet the Medicare criteria for SNF care. 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 for the skilled nursing services provided from September 11, 2019 to October 10,
2019.