Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe Leuprolide acetate (J9217) provided on June 11, 2020.You asked the Planto waive the coinsurance forLeuprolide acetate. You say that you do not agree with the coinsurance you are being charged.The Plan denied your request. The Plan says the coinsurance applied correctly in this case.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay a total cost share of $282.44 for the Leuprolide acetate ($1,412.22 x 20% = $282.44). Leuprolide acetate falls within the Medicare Part B prescription drugs benefit category. Of note, although you received the drug out-of-network, the Plan agreed to process at the in-network benefit of 20% coinsurance. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the coinsurance forthe Leuprolide acetate (J9217) provided on June 11, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forlaboratory services provided on July 21, 2020.You asked the Plan to waive the copayment forlaboratory services. You say that the labs were taken as part of your annual wellness exam so you should not owe the copayment.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 $10 copayment for lab services. You received laboratory services on July 21, 2020. Laboratory services are not included in annual wellness visits. Therefore, you are responsible to pay the $10 copayment. You have been asked to pay a $10 copayment for laboratory services. Laboratory services fall within the outpatient diagnostic tests and therapeutic services and supplies 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 forlaboratory services provided on July 21, 2020
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approvea low dose CT scan of the lungs for the enrollee.You asked the Plan to pre-approvethe scan. You say that you would like to screen for disease in the lungs.The Plan denied your request. The Plan says that imaging may be supported if the scan has not been done in the last twelve months.The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the scan. Our reviewer says that the requested scan is medically reasonable and necessary. Our physician reviewer found the enrollee meets all of the CMS guidelines for annual LDCT for lung cancer screening.  Her most recent scan is greater than 12 months ago (10/29/19).  Thus the request for LDCT of the chest should be approved.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 scan have been met.Therefore, we decided that the Plan has to pre-approvea low dose CT scan of the lungs for the enrollee.
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 toopen the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea medical alert bracelet.You asked the Plan to pre-approvethe medical alert bracelet. You say that you would like reconsideration because this bracelet is medically necessary due to your condition.The Plan denied your request. The Plan says this service is not covered by Medicare.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The rules also say that Telephone Alert Systems are non-covered because they are emergency communications systems and do not serve a diagnostic or therapeutic purpose.The item at issue in this appeal is a Telephone Alert System. This item is not a Medicare covered benefit.Therefore, we decided that the Plan does not have to pre-approvea medical alert bracele
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvespecialist services to be provided by an out of network (OON) provider.You asked the Plan to pre-approvespecialist services. You say that you would like approval for these services.The Plan denied your request. The Plan says there are in-network providers available.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-approvespecialist services to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
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 the enrollee does not meet the criteria for coverage.
The Plan must follow Medicare rules. Medicare rules say that a therapeutic CGM is covered when specific criteria are met. We looked at the file and Medicare rules. The file shows that the enrollee does not adjust insulin dosing frequently based on blood sugar testing and does not need more than three injections of insulin per day. 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 a continuous glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe initial periapical x-ray (D0220), the additional periapical x-ray (D0230), and the incision and drainage of an abscess (D7510) provided on July 28, 2020.You asked the Plan to pay forthe dental services. You say that the services should be covered.The Plan denied your request. The Plan says periapical x-rays are not listed as covered services. The Plan says incision and drainage of an abscess is not listed as a covered service either.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 forthe initial periapical x-ray (D0220), the additional periapical x-ray (D0230), and the incision and drainage of an abscess (D7510) provided on July28, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pulse oximeter (E0445).
You asked the Plan to pre-approve the pulse oximeter. You say that you would like reconsideration because your doctor ordered the device in order to get a diagnosis and treat you. The Plan denied your request. The Plan says oximeters are not covered by Medicare or the Plan.
The Plan must follow Medicare rules. Medicare rules say that oximeters (E0445) and replacement probes (A4606) will be denied as non-covered because they are monitoring devices that provide information to the treating practitioner to assist in managing the beneficiary's treatment. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the pulse oximeter have not been met. Specifically, the request pulse oximeter is not covered by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve a pulse oximeter (E0445).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea power operated vehicle (K0800).You asked the Plan to pre-approvea power operated vehicle. You say that you need this to help you move around.The Plan denied your request. The Plan says the criteria for coverage have not been met.The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home. The records show that this was specifically ordered for mobilization in public. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home.Therefore, we decided that the Plan does not have to pre-approvea power operated vehicle (K0800).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided  that the  Plandoes not haveto pre-approveadmission  to an inpatient  rehabilitation  facility  (IRF).You asked the Planto pre-approveIRF care. You  say that this  is  medically  necessary.The  Plandenied  your request. The  Plansayscare could  be received  in  another  setting.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  you  do not require  the intensity  of  services  provided  at an IRF.  Specifically,  you  are not shown  to require,  or to be tolerating,  fifteen  hours  per week of rehabilitative  services  and regular  physician evaluation.  Your  care needs  can be met  at a lower  level  of  care (ex.  SNF/SAR).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  Plandoes not haveto pre-approveadmission  to an inpatient  rehabilitation  facility  (IRF).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe domiciliary visit (99335) provided on February 11, 2020 by an out of network (OON) provider.You asked the Plan to pay fordomiciliary visit. You say that medically necessary services were rendered in good faith.The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services rendered by an out-of-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. 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 visit (99335) provided on February 11, 2020 by an out of network (OON) provider
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance transportation to a second skilled nursing facility (SNF).
You asked the Plan to pay for ambulance transportation. You say that you need ambulance transportation to the new SNF. The Plan denied your request. The Plan says transportation to the new facility is not covered.
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when they meet certain origin and destination requirements. Ambulance transportation is covered to a hospital or skilled nursing facility capable of furnishing the appropriate care for a patient's illness or injury. The services you have asked the Plan to pay for the are ambulance transport services to a second SNF. Since you are already being covered in a SNF that is able to provide a sufficient level of coverage and this request for a second SNF is preference based, this request for transportation is not approved.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you forthe periodontal maintenance (D4910) provided on July 9, 2020.You asked the Plan to reimburse you forthe dental service. You say that it is indisputable that routine periodontal hygiene is a preventive dental service that you require in the judgement of your dentist. You also say that the statement in the Annual Notice of Changes regarding dental coverage does not make any sense.The Plan denied your request. The Plan says periodontal maintenance is not considered routine in nature, nor a preventive dental service.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. Periodontal maintenance is related to periodontal issues that are neither routine or preventive.Therefore, we decided that the Plan does not have to reimburse you forthe periodontal maintenance(D4910) provided on July 9, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the preventive procedure (D1999), complete series of
intraoral x-rays (D0210), and comprehensive oral evaluation (D0150) provided on July 30, 2020.
You asked the Plan to pay for the preventive procedure, complete series of intraoral x-rays, and comprehensive
oral evaluation. You say that you went to a new provider and needed the exam, x-rays, and cleaning. You also
say that you were not aware that the exam and x-rays were only covered once every 36 months. The Plan
denied your request. The Plan says the preventive procedure is not a covered benefit. The Plan also says that
the complete series of intraoral x-rays and comprehensive oral evaluation exceed the frequency limitation in
your benefit 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, unspecified preventive procedure is not
among those covered under this benefit. The Plan contract clearly states that complete series of intraoral x-rays
(D0210) and comprehensive oral evaluation (D0150) are each limited to one procedure every three plan years.
The record shows that you received a complete series of intraoral x-rays (D0210) and comprehensive oral
evaluation (D0150) on November 26, 2019, and your complete series of intraoral x-rays (D0210) and
comprehensive oral evaluation (D0150) benefits have been exhausted. Therefore, we decided that the Plan does
not have to pay for the preventive procedure (D1999), complete series of intraoral x-rays (D0210), and
comprehensive oral evaluation (D0150) provided on July 30, 2020.
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 you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission is not medically necessary.
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 for CoViD-19. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and acute care hospitals 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. 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. You say that you want to go to a rehab center and not an assisted living facility. You also say that you want to be able to get well enough to live alone like you were previously.The Plan denied your request. The Plan says the criteria for admission to the Acute Inpatient Rehabilitation setting have 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 relevantMedicare 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 does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer found that you do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The medical record supports a need for physical and occupational therapy, but it does not support a need for an intensive rehabilitation therapy program. Our physician reviewer also found that there is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.We looked at this physician's review, the file,and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute IRF admission and services
Appeal type: Practitioner Services
Decision: Unfavorable

We decided  that  the  Plan  does not  have to pre-approvea spinal  cord stimulator  (SCS) implantation.You asked the  Plan to pre-approvethese  services.  You  say that the  services  are medically  necessary.The  Plan denied  your  request.  The  Plan  says the  services  are not medically  necessary.The  Plan  must  follow  Medicare  rules.  Medicare  rules  say  that  SCS is  covered  when  specific  criteria  are met.We asked our physician  reviewer  to carefully  review  thecase 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  services  are not medically  necessary.  Our physician  reviewer  found  the  enrollee  has chronic  low  back pain for  20 years. She is  not  considered  a surgical  candidate  when  evaluated  by the  consultant.  She has  not had any intrathecal  medication  trials.  There  is  no documented  evidence-based  indication  for the  SCS. The  services  are 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 pre-approvea spinal  cord stimulator  (SCS) implantation
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the periodontal scaling and root planing (D4342).
You asked the Plan to pre-approve the periodontal scaling and root planing. You say that this service is
medically necessary to treat your medical condition. The Plan denied your request. The Plan says this service is
not covered.
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
periodontal scaling and root planing (D4342).