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

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that you need additional care and physical therapy. The Plan denied your request. The Plan says that skilled nursing facility services are only covered up to 100 days per benefits period.
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. The file shows that you received 100 days of SNF care during the benefit period from January 10, 2020 through April 18, 2020. The Plan has covered 100 days of SNF care. Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. You will be eligible for a new benefit period when you have not been receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
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 had colon cancer and had to have over twenty four inches of your colon removed. You say that you are dual incontinent and you feel like the requested supplies should be covered for you under your medical benefits. You stated that it difficult for you to afford the requested supplies and they are necessary to allow you to participate in normal activities outside of your home.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: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided on October 27, 2019 through October 29, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that you would like reconsideration because the services rendered were medically necessary. The Plan denied your request. The Plan says that inpatient admission was 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 record showed that at the time of inpatient admission the admitting physician reasonably expected that the member's necessary hospital care (including earlier 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 on October 27, 2019 through October 29, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a walk-in bathtub.You asked the Plan to pre-approve a walk-in bathtub. You say that you are unable to use a standard bath tub due to injuries to both legs.The Plan denied your request. The Plan says that hygienic equipment is not covered as it is not primarily medical in nature.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plan does not have to pre-approve a walk-inbathtub.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for transportation provided on November 4, 2019 and November 20, 2019.
You asked the Plan to pay for the routine transportation services. You say that the Plan's transportation service is unreliable. The Plan denied your request. The Plan says you did not use the required service provider.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pay for transportation provided on November 4, 2019 and November 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network chiropractic care provided from September 13, 2019 to February 3, 2020.
You asked the Plan to pay for out of network care chiropractic care. You say that you did not know this provider was out of network. The Plan denied your request. The Plan says you did not have prior authorization for chiropractic care, and you did not have prior authorization to use 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 must pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The contract with the Plan also says that chiropractic services require prior authorization. This provider is not a network provider with the Plan. The Plan has network providers available who can provide chiropractic services. The Plan did not pre-approve these services. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for out of network chiropractic care provided from September 13, 2019 to February 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chiropractic treatments. You asked the Plan to pre-approve chiropractic treatments. You say that the services are necessary to relieve the enrollee's pain until she is able to get surgery. 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 Medicare does not cover chiropractic maintenance care. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve chiropractic treatments. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has received treatment from March 27, 2020 through May 6, 2020. The submitted chart notes reveal no evidence of improvement; with no evidence that further clinical improvement can reasonably be expected from continuous ongoing care. In addition to treatment of two week intervals, with no significant clinical support, along with the enrollee's neck disability indices of 70% on March 27, 2020 and 74% on April 16, 2020, there is no evidence of improvement. Treatment is to prevent deterioration of a chronic condition, which is maintenance therapy and is not supported or allowed per Medicare guidelines. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of chiropractic treatments have not been met. Therefore, we decided that the Plan does not have to pre-approve chiropractic treatments.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (99214) provided February 6, 2020.
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The Plan denied your request. The Plan says Original Medicare is liable for coverage.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for physician services (99214) provided February 6, 2020.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Tudorza Pressair inhaler.
You asked the Plan to pre-approve a Tudorza Pressair inhaler. You say that you would like the Plan to
reconsider their denial. The Plan denied your request. The Plan says a Tudorza Pressair inhaler is not covered
under the enrollee's Medicare Part B benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 a Tudorza Pressair inhaler.
Benefits for a Tudorza Pressair inhaler 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from January 13, 2020 through January 14, 2020.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 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 does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the medical records showed the surgeon intended this to an observation status hospitalization with an overnight stay (documented in the preoperative evaluation). The records also indicated were no post-operative complications. You were discharged home January 14, 2020 with outpatient follow-up. The review has determined that the record did not show 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 not been met.Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from January 13, 2020 through January 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on December 4, 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 Medicare says tests with no relation to a diagnosis for the health of the patient are not a benefit.
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 pay for the services. Our reviewer says that the services at issue in this case are not medically reasonable or necessary. Our physician reviewer found in the case of this enrollee, an order for various testing including vitamin d, lipid panel, urinalysis, comprehensive metabolic panel, HgbA1C, free thyroxine, TSH, and CBC was completed on 12/4/2019 for the listed diagnoses: encounter for screening for other disorder, body mass index 19.9 or less, and other long term current drug therapy. No other clinical information was provided to help describe the exact conditions, signs or symptoms, or medications being used and why screening or monitoring was needed via these blood and urine tests for this patient. The provided diagnoses are not appropriate or specific enough to justify the above tests. Therefore, without sufficient support made for this request, the tests completed on 12/4/2019 will be considered not medically necessary at this time. 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 services have not been met. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on December 4, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for Ostomy deodorant, with or without lubricant, for use in
ostomy pouch, per fluid ounce (A4394), Ostomy skin barrier, with flange (solid, flexible, or accordion),
extended wear, with built-in convexity, 4 x 4 inches or smaller, each (A4407) and Ostomy pouch, drainable; for
use on barrier with flange (2 piece system), each (A5063) provided to the enrollee on November 18, 2019.
You asked the Plan to pay for the durable medical equipment (DME). You say that the claim should be paid.
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 durable medical equipment (DME) have not been met.
Healthcare Common Procedure Coding System (HCPCS) code A5063 (60 Units) remains not supported. The
documentation submitted did not include an itemized shipping/billing invoice to corroborate with the proof of
delivery. Therefore, the billed supply code cannot be verified. It is noted that multiple attempts were made to
contact the provider for additional information.
Healthcare Common Procedure Coding System (HCPCS) code A4407 (60 Units) remains not supported. The
documentation submitted did not include an itemized shipping/billing invoice to corroborate with the proof of
delivery. Therefore, the billed supply code cannot be verified. It is noted that multiple attempts were made to
contact the provider for additional information.
Healthcare Common Procedure Coding System (HCPCS) code A4394 (24 Units) remains not supported. The
documentation submitted did not include an itemized shipping/billing invoice to corroborate with the proof of
delivery. Therefore, the billed supply code cannot be verified. It is noted that multiple attempts were made to
contact the provider for additional information. Therefore, we decided that the Plan does not have to pay for
Ostomy deodorant, with or without lubricant, for use in ostomy pouch, per fluid ounce (A4394), Ostomy skin
barrier, with flange (solid, flexible, or accordion), extended wear, with built-in convexity, 4 x 4 inches or
smaller, each (A4407) and Ostomy pouch, drainable; for use on barrier with flange (2 piece system), each
(A5063) provided to the enrollee on November 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on March 3, 2020.
You asked the Plan to waive the copayment for the specialist office visit. You say that you discussed with the doctor that you did not want the cataract surgery yet. You say that you should not be charged because nothing happened at this 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 $50 copayment per visit for a specialist office visit. You have been asked to pay a $50 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" 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 specialist office visit provided on March 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for bone growth stimulator (E0747) purchased June 3, 2019. You asked the Plan to pay for bone growth stimulator. You say that your surgeon strongly recommended this device when he performed the surgery on 2/12/19. He emphasized that it was very important to use the device to reduce the chances of a non-union. The Plan denied your request. The Plan says this request does not meet the medical necessity criteria. The Plan must follow Medicare rules. The rules say that an electrical bone stimulator is covered for nonunion of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial radiographs have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment with the electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs separated by a minimum of 90 days. 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 bone growth stimulator. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee underwent elective right cavovarus foot correction on 2/12/19, less than 2 months prior to initiation of bone growth stimulation. There is no evidence of a nonunion. Progressive healing was documented on the serial post-operative radiographic reports. Delayed healing of the tibial osteotomy was reported as of 5/13/19. There are no risk factors for failed fracture healing documented in the submitted medical records to support the medical necessity of this request as an exception to guidelines. Therefore, the request for an electrical osteogenesis stimulator would not be considered reasonable and 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 bone growth stimulator have not been met. Therefore, we decided that the Plan does not have to pay for bone growth stimulator (E0747) purchased June 3, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided to the enrollee on August 22,
2019 and September 10, 2019 by an out-of-network provider.
You asked the Plan to pay for the dental services. You say that the enrollee's card does not state there are no
out-of-network benefits. The Plan denied your request. The Plan says the enrollee does not have out-of-network
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.
The provider is not in-network and the enrollee's EOC clearly states, EXCLUSIONS AND LIMITATIONS -
PLAN LEVEL: Services performed by an out-of-network dentist if your plan does not have out-of-network
coverage. Therefore, we decided that the Plan does not have to pay for the dental services provided to the
enrollee on August 22, 2019 and September 10, 2019 by an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of a superion ISS interspinous spacer to the lumbar spine region.You asked the Plan to pre-approve insertion of a superion ISS interspinous spacer to the lumbar spine region. You say that you would like the plan to reconsider their denial The Plan denied your request. The Plan says the requested services are not medically necessary.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 insertion of a superion ISS interspinous spacer to the lumbar spine region. 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 multi-level degenerative disc disease, facet joint disease and spinal stenosis. The enrollee's spinal stenosis involves two levels L4-L5 and L5-S1. The enrollee had minimal response to Transforminal Epidural steroid injections. There is lack of adequate patient studies to demonstrate superior efficacy of this device relative to other surgical options. This device is investigational and the published studies address the placement of single level, not two level insertions.We looked at this physician's review, the file,and Medicare rules. Based on this information, we decided that Medicare rules for coverage of insertion of a superion ISS interspinous spacer to the lumbar spine region have not been met.Therefore, we decided that the Plan does not have to pre-approve insertion of a superion ISS interspinous spacer to the lumbar spine region.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids provided on December 11, 2019.
You asked the Plan to pay for the hearing aids. You say that you believe you have a responsibility due because the Plan did not pay the charges. The Plan denied your request. The Plan says they paid $2000.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Per the provider's office, the total charge for services was $4926.00. You paid up front, $3375.50 out of pocket. The Plan paid $2000.00 leaving an overpayment of $449.50 which was refunded to you. Therefore, we decided that the Plan does not have to pay for the hearing aids provided on December 11, 2019.