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

We decided that the Plan does not have to pay for diabetic shoes provided on August 28, 2019 by an out of
network (OON) provider.
You asked the Plan to pay for diabetic shoes. You say that you would like this appeal reprocessed and
approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained.
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 diabetic shoes provided on August 28, 2019 by an
out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2750) for tooth # 30.You asked the Plan to pre-approve the dental service. You say that the enrollee fractured tooth # 30. You also say that there is a big old restoration done and it covers almost the whole tooth.The Plan denied your request. The Plan says the crown is not medically necessary. The Plan also says the tooth does not appear to have significant breakdown.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 Plan covers the dental service when the services are medically necessary and reasonable. 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 dental service. Our reviewer says that the requested dental service is not medically necessary. Our physician reviewer found the provided documentation shows a temporized tooth # 30 with recurrent occlusal decay, a distal marginal ridge fracture and a weakened unsupported mesial marginal ridge. The reviewer found that if the tooth is restored conventionally, it would involve three surfaces and would not involve replacing any cusps. Therefore, the reviewer found that the requested crown 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 the Plan's rules for coverage of the dental service have not been met.Therefore, we decided that the Plan does not have to pre-approve a crown (D2750) for tooth # 30.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health aide services rendered to you from September 7, 2019 to October 18, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the provider is not Medicare-certified.
The Plan must follow Medicare rules. The rules say that Medicare pays for services only when they are furnished by a provider or supplier enrolled in the Medicare program. The file shows that the provider was not Medicare-certified during the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the home health aide services rendered to you from September 7, 2019 to October 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea home ultraviolet light box.You asked the Plan to pre-approvea home ultraviolet light box. You say that the use of this equipment at home would be beneficial for the enrollee.The Plan denied your request. The Plan says based on the medical records provided, the enrollee does not have generalized intractable psoriasis. While this equipment may be helpful for the enrollee's condition, Medicare only covers home phototherapy for persons with generalized intractable psoriasis. The Plan covers all items that Medicare covers. Medicare rules state that ultralight boxes are covered only under certain conditions. The medical records do not indicate the enrollee meets those criteria. Therefore, we decided that the Plan does not have to pre-approvea home ultraviolet light box.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral for stereotactic body radiation therapy/CyberKnife with an out-of-network provider.
You asked the Plan to pre-approve the referral. You say that the plan should consider the Cyber Knife machine that is not offered anywhere in Rhode Island. The Plan denied your request. The Plan says there is no indication of an emergent or urgent service need, or a need for expertise beyond what is available in the plan's network.
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 referral. Our reviewer says that the requested referral is not considered medically reasonable and necessary in this case. Our physician reviewer found standard therapies for early stage prostate cancer include prostatectomy, interstitial brachytherapy and IMRT delivered over 7+ weeks (or shorter courses with ~2.5 Gy fractions- as being investigated in a national cooperative group trial). Proton therapy is also an option, though probably does not confer any advantage over IMRT. Stereotactic body radiotherapy (SBRT), delivering high fractional doses to the prostate in 3-5 fractions is an emerging approach to the treatment of prostate cancer. Cyberknife is somewhat different that other conventional LINACs. The Cyberknife is a delivery system which allows for SBRT, using real time monitoring of the patient coupled with robotically controlled tracking of the patient. However, there are multiple commercial systems that facilitate delivery of SBRT. It is not plausible that SBRT could not as effectively and as safely be delivered by an in network radiation oncology practice. Seeking out of network care for a commercial system that is not available in network would only be necessary if the same treatment could not be offered in network- which does not apply to this case. As such, out of network care would exceed your needs. 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 referral have not been met. Therefore, we decided that the Plan does not have to pre-approve a referral for stereotactic body radiation therapy/CyberKnife with an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve fitness center benefits. You asked the Plan to pre-approve fitness center benefits. You say that a convenient fitness center membership is needed for your health. The Plan denied your request. The Plan says that they do not offer a fitness benefit beyond those obtained as part of the membership. The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers gym benefits only when part of a certain program. The Plan's rules for coverage of gym benefits have not been met because you are requesting coverage outside of this program. Therefore, we decided that the Plan does not have to pre-approve fitness center benefits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the topical application of fluoride (D1208).
You asked the Plan to pre-approve the dental services. You say that this service will help to prolong the
longevity of the enrollee's remaining teeth. The Plan denied your request. The Plan says this service is not
covered under the plan 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 pre-approve the
topical application of fluoride (D1208).
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from September 13, 2019 through September 19, 2019. You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The Plan denied your request. The Plan says that the stay is not medically necessary. The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (ED) and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from September 13, 2019 through September 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance provided on January 2, 2020.You asked the Plan to pay for the periodontal maintenance. You say that you understand that the periodontal maintenance procedure is not a covered benefit. You also say that you feel that the customary and reasonable allowance for a cleaning should be allowed.The Plan denied your request. The Plan says periodontal services are not a covered benefit.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 periodontal maintenance provided on January 2, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided on July 22, 2019.
You asked the Plan to pay for the self-administered drugs. You say that the enrollee was unable to bring in his own medication to the hospital with him. You also say that the enrollee needs to take the drugs every day. The Plan denied your request. The Plan says Medicare generally does not pay for drugs that an enrollee usually self-administers such as drugs in pill form and those used for self-injection. The Plan also says that if the enrollee receives self-administered drugs that are not covered by Medicare Part B while in a hospital outpatient setting, the hospital may bill the enrollee for the drug.
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 pay for the self-administered drugs provided on July 22, 2019.
Benefits for these self-administered drugs 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 copayment forthe physical therapy services provided on November 26, 2019.You asked the Plan to waive the copayment forthe physical therapy services. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request.The Plan denied your request.The Plan says you received physical therapy on the date of service at issue in this appeal. The Plan states the correct copayment has applied per your contract with the Plan.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 Outpatient rehabilitation services. We looked at the file, the Plan's contract and Medicare rules. The file shows you received physical therapy on November 26, 2019. You have been asked to pay a $40 copayment for the physical therapy services. The physical therapy services 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 copayment forthe physical therapy services provided on November 26, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Oxycodone tab 60mg ER for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the requested medication is denied as a benefit exclusion.
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 Oxycodone tab 60mg ER for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve custom foot orthotics.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says you do not have a condition for which these services are covered.
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-approve custom foot orthotics.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay forthe replacement face mask rendered on November 4, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says that the enrollee's coverage ended on November 1, 2019.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. ThePlan states that the enrollee termed coverage with the Plan on November 1, 2019; however, the Medicare Beneficiary Database confirms that the enrollee was enrolled in the Plan contract at issue until November 30, 2019. There is no documentation to supportthat the claim is not payable.Therefore, we decided that the Plan has to pay forthe replacement face mask rendered on November 4, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe presumptive and definitive drug testing rendered on October 30, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the testing was not medically necessary.The Plan must follow Medicare rules. Medicare rules say that presumptive and definitive drug testing is covered when specific criteria are met.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 these services. Our reviewer says that the testing was not medically necessary. Our physician reviewer found the enrollee has chronic pain syndrome maintained on opiate therapy. The submitted documentation does not contain progress notes that support the clinical utility of the testing. The records do not show that the criteria for coverage are met. The presumptive and definitive drug testing was not reasonable or 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 these services have not been met.Therefore, we decided that the Plan does not have to pay forthe presumptive and definitive drug testing rendered on October 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four monitoring (95999) provided on February 25, 2020.
You asked the Plan to pay for train of four monitoring. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this item or service is considered a bundled procedure as the cost is included in the cost of the primary procedure.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 95999 is not supported in the record. Specifically, Medicare does not make separate payment for train of four monitoring as it is considered integral to the primary service. Based on this information, we decided that Medicare rules for coverage of train of four monitoring have not been met. Therefore, we decided that the Plan does not have to pay for train of four monitoring (95999) provided on February 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on September 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 knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on September 9, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care provided to the enrollee from December 29, 2018 through December 31, 2018.
You asked the Plan to pay for inpatient hospital care. You say that the claim should be paid. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required.
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 inpatient hospital care. Our physician reviewer found all inpatient care provided after 12:19 p.m. on December 29, 2018 through 10:30 p.m. on December 31, 2018 was not needed on an emergent basis. The review has determined that the treating physician did not document (in the physician notes, on a form, or in an order) that the patient was not stable for transfer on any dates of service. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for inpatient hospital care provided to the enrollee from December 29, 2018 through December 31, 2018.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadditional home health aide hours for the enrollee.You asked the Planto pre-approvethe additional hours. You say that this is medically necessary.The Plandenied your request. The Plansays10.5 hours are appropriate given the new decision time tool.The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or 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 the additional hours. Our reviewer says that the requested aide hours are not medically reasonable or necessary. Our physicianreviewer found the documentation does not indicate that the full 19 hours/weekly are medically necessary. The documentation indicate the patient was receiving a skilled nursing services 7 days per week but the documentation does not support that 19 hours/weekly are necessary for a home health aide per the time for task tool. The enrollee's daughter assists with IADL care including medication management. The documentation does not reveal extenuating factors that indicate the additional hours/weekly beyond what was approved by the health plan is medically needed for the treatment of the enrollee's illness or injury.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 additional hours have not been met.Therefore, we decided that the Plandoes not haveto pre-approveadditional home health aide hours for the enrollee.