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

We decided that the Plan does not have to pay for knee orthosis (L1833) and suspension sleeve (L2397)
provided to the enrollee on January 10, 2020.
You asked the Plan to pay for the orthosis and sleeve. You say that the durable medical equipment is medically
necessary. The Plan denied your request. The Plan says the services are not supported by the records.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the orthosis and sleeve have not been met. Documentation
submitted did not indicate the provider discussed the need for the billed supply code; therefore the billed supply
code cannot be verified. Therefore, we decided that the Plan does not have to pay for knee orthosis (L1833) and
suspension sleeve (L2397) provided to the enrollee on January 10, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower/bath chair.
You asked the Plan to pre-approve the chair. You say that you are overweight and have fallen in the tub in past, and injured your knee. The Plan denied your request. The Plan says this is considered a comfort and convenience item.
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-approve a shower/bath chair.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says that no skilled therapies or nursing care needs are identified.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on December 13, 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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 for the drug testing rendered on December 13, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve breast implant surgery (19340). You asked the Plan to pre-approve this service. You say that breast implant replacement is medically necessary. The Plan denied your request. The Plan says that breast implant replacement surgery is considered by Medicare to be cosmetic in members without a history of a medically necessary mastectomy. The Plan must follow Medicare rules. Medicare rules say that cosmetic surgery or expenses incurred in connection with such surgery, for the sole purpose of improving one's appearance, is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve this service. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found that this enrollee has evidence of typical complications following bilateral breast augmentation, implant rupture and painful capsular contracture. This has created a functional impairment that is well-documented. However, the medically necessary aspect of this case relates to relieving the functional impairment, which could be accomplished in the most effective manner with implant removal and capsulectomy. Implant replacement would be considered in the same manner as the enrollee's original cosmetic breast augmentation, namely, a cosmetic procedure. Per the Medicare Benefit Policy Manual cosmetic surgery or expenses incurred in connection with such surgery, for the sole purpose of improving one's appearance, is not covered. Thus, implant replacement does not satisfy Medicare medically necessary criteria. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pre-approve breast implant surgery (19340).
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from June 24, 2019 through
June 30, 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 indicates 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 June 24, 2019 through June 30, 2019.
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 alveoloplasty not in conjunction with extractions (D7320) provided by an OON provider on December 31, 2019.
You asked the Plan to pay for the alveoloplasty. You say that the Xgeva caused your left mandible to grow through your left lower gum and protrude into your mouth. You also say that the jagged end of this protrusion cut your tongue whenever you swallowed, which caused you constant pain. The Plan denied your request. The Plan says unless your plan approves it, the Plan only covers services done by your assigned dentist.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the alveoloplasty not in conjunction with extractions (D7320) provided by an OON provider on December 31, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy (S9328) provided October 21, 2019 to December 4, 2019.
You asked the Plan to pay for HCPCS code S9328. You say that you are requesting reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was billed with an invalid code, not payable by Medicare.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate HCPCS/CPT code. We find that CPT code S9328 is not supported in the medical record. Specifically, CPT code S9328 has a status indicator of I and will not be paid by Medicare. This service should be reported with a code that is recognized by Medicare. Based on this information, we decided that Medicare rules for coverage of this CPT code S9328 have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy (S9328) provided October 21, 2019 to December 4, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the power mobility device (incorrectly coded as E1399 to describe a Jazzy Passport folding power chair) provided on January 10, 2020.
You asked the Plan to pay for the DME. You say that there was no payment on this claim and that this wheelchair has helped with progression of walking. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. Your records show that you have non-specific illness related to a recent shoulder arthroplasty.
The record sent by your provider indicates that you had the shoulder replacement surgery but there is no description regarding mobility related activities of daily living, face to face examination, home assessment or detailed written order from your provider. Therefore, we decided that the Plan does not have to pay for the power mobility device (incorrectly coded as E1399 to describe a Jazzy Passport folding power chair) provided on January 10, 2020.
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 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 the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your current medical comorbidities are chronic and stable and your medical status does not require intensive physician or nursing oversight in an IRF. You may benefit from additional multiple therapies, however your functional level does not require that this therapy must be in an IRF with an intensive level program. 
 
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-rays provided on October 31, 2019.
You asked the Plan to pay for the x-rays. The Plan denied your request. The Plan says there is no additional documentation supporting additional studies which were billed.
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined to be exact duplicates of another claim are denied.
The documentation shows the enrollee received an x-ray for the shoulder, cervical spine and lumbar spine. We find that the services at issues have already been processed and paid for by the plan. Duplicate claims are not covered. Therefore, we decided that the Plan does not have to pay for the x-rays provided on October 31, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office visit with a non-contracting optometrist.
You asked the Plan to pre-approve the services. You say that you want to see a new doctor because you do not trust the other provider who misdiagnosed you. The Plan denied your request. The Plan says care received from an out-of-network provider will not be covered unless it is emergency care or urgently needed services, medical care that Medicare requires the plan to cover and the providers in the network cannot provide the care, or if it is for kidney dialysis services at a Medicare-certified dialysis facility.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and 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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve office visit with a non-contracting optometrist.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an assisted living visit provided on December 18, 2019 by an out of network (OON) provider.You asked the Plan to pay for an assisted living visit. You say that these services were provided in an assisted living home.The Plan denied your request. The Plan says the member's assisted living facility is out-of-network. The Plan says that 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. ThePlan 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 foran assisted living visit provided on December 18, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urgent care visit provided on January 7,
2020.
You asked the Plan to waive the copayment for the urgent care visit. You say that you were advised that you
would not have responsibility for the visit. 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 urgent care visit.
You have been asked to pay a $40 copayment for the urgent care visit. The urgent care visit falls within the
"Urgently needed 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 for the urgent
care visit provided on January 7, 2020.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dentures.
You asked the Plan to pre-approve the dentures. You say that you would like the lower denture replaced, as you lost the lower denture. The Plan denied your request. The Plan says the benefit is exhausted.
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 dentures once every sixty months. You received the prior denture less than five years ago on 5/6/20. Based on this information, we decided that the Plan's rules for coverage of the dentures have not been met. Therefore, we decided that the Plan does not have to pre-approve dentures.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. 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 LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH) following mitral valve surgery that was complicated by an embolic stroke. The enrollee is not currently intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care (LTC) 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services you received on November 27, 2019.
You asked the Plan to pay for the services. You say that this should be covered as out-of-network. The Plan
denied your request. The Plan says this provider does not accept Medicare.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary
for items or services provided directly by a physician or practitioner who has opted out of the program except
in cases involving emergencies or urgently needed care.
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by a provider that
has opted out of the Medicare program. The file shows that this provider entered into a private contract with
you regarding payment. Therefore, we decided that the Plan does not have to pay for the services you received
on November 27, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Inogen concentrator.You asked the Plan to pre-approve a concentrator. The Plan denied your request.The Plan says that Medicare does not cover purchased oxygen equipment, your provider did not order this device for you and your oxygen needs can be provided by rental of approved equipment.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 physician order for the requested concentrator.Therefore, we decided that the Plan does not have to pre-approvean Inogen concentrator
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Calcitriol.
You asked the Plan to pre-approve Calcitriol. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not a covered benefit.
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 Calcitriol.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Vitamin D testing provided on January 16, 2020.
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the service is
not a Medicare benefit for the diagnoses listed on the claim.
The Plan must follow Medicare rules. Medicare considers vitamin assay panels a screening procedure and
therefore, non-covered.
In this case, the CPT Code Manual definition of code 82306 is Vitamin D; 25 hydroxy, includes fraction(s), if
performed. We find that CPT code 82306 is not supported in the medical record. The documentation does not
show the service was billed with a valid and covered diagnosis for the testing. Based on this information, we
decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that
the Plan does not have to pay for the Vitamin D testing provided on January 16, 2020.