Persius/hicric huggingface dataset:
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. You say that these services are medically necessary. The Plan denied your request. The Plan says that you have no skilled therapy or skilled nursing service needs.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 your 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic continuous glucose monitor (CGM) supplies provided on December 15, 2020.
You asked the Plan to pay for the CGM supplies. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the items received are not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of the CGM supplies have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic continuous glucose monitor (CGM) supplies provided on December 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for ophthalmological services that you provided on
February 25, 2020.

You asked the Plan to pay for the ophthalmological services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.

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 did not pre-approve the services at issue. 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 ophthalmological services that you provided on
February 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids (V5298) provided on July 3, 2020.
You asked the Plan to pay for the hearing aids. You say that you were told your husband had full coverage for hearing devices and you say that your Plan generally covers out-of-network medical services. The Plan denied your request. The Plan says hearing aids will only be covered under the supplemental hearing benefit when purchased from the Plan's hearing provider as specified in your contract.
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. The Plan pays for hearing aids only when they are provided by the Plan's specified hearing vendor. 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. Therefore, we decided that the Plan does not have to pay for hearing aids (V5298) provided on July 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the complete upper denture (D5110), and a complete lower denture (D5120) provided on January 4, 2021.
You asked the Plan to pay more for the dental items. You say that you did not receive the dentures until 2021. You say that you believe that your benefits should have been rolled over to the new quarter. You say that the dentures should have been paid in full. You also say that the charges applied as your responsibility should be removed. The Plan denied your request. The Plan says there is a maximum allowed amount of $400 per quarter. The Plan says that the maximum allowed amount per quarter has been 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. Though the Plan offers a dental benefit in excess of Medicare coverage, there is a maximum allowed amount of $400 per quarter that has been exhausted. The record shows that the Plan paid $400 towards the complete upper denture. The Evidence of Coverage clearly states that unused quarterly allowance carries over to the next quarter but does not carry over to the next year. Benefit resets December 31 of each year. Therefore, we decided that the Plan does not have to pay more for the complete upper denture (D5110), and a complete lower denture (D5120) provided on January 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair with a single power feature
(K0856, E2361, E1028, E1002, E2620, E0955, E1028, E0953, E1028,
E2310, E2601).
You asked the Plan to pre-approve the group 3 power wheelchair with a single power feature. You say that the
group 3 power chair with power options is medically necessary. The Plan denied your request. The Plan says
coverage rules are not met.
The Plan follows Medicare rules. Medicare rules say that this type of power chair is covered when 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 group 3 power wheelchair with a
single power feature. Our reviewer says that the group 3 power chair with power options is not medically
necessary. Our physician reviewer found the enrollee is continent. His history is not consistent with being at
high risk for development of pressure ulcers. The enrollee does not utilize intermittent catheterization for
bladder management. The power options are not 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 the group 3 power wheelchair with a single power feature have not been met.
Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair with a single
power feature (K0856, E2361, E1028, E1002, E2620, E0955, E1028, E0953, E1028,
E2310, E2601).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forhome infusion therapy services (99601 and 9962) provided on October 19, 2020.You asked the Plan to pay forthe home infusion therapy services. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says CPT codes 99601 and 99602 have status indicators of I and are not valid for Medicare purposes.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 codes 99601 and 99602 are not supported in the record. Specifically, perthe Physician Fee Schedule, CPT codes 99601 and 99602 have status indicators of I. This means that CPT codes 99601 and 99602 are not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy services have not been met.Therefore, we decided that the Plan does not have to pay forhome infusion therapy services (99601 and 9962) provided on October 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the physician services rendered on January 6, 2021.
You asked the Plan to waive the copayment for these services. You say that there should be no copayment for a telehealth visit. The Plan denied your request. The Plan says the copayment was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $25 copayment for each covered visit or consultation in an outpatient location with a specialist.
Review of the file shows that the enrollee received specialist services via telehealth on January 6, 2021. The enrollee has been asked to pay a $25 copayment for these services. These services fall within the covered visit or consultation in an outpatient location with a specialist benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the physician services rendered on January 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller for a power wheelchair (E2377, E2313, E2311).
You asked the Plan to pre-approve the expandable controller for a power wheelchair. You say that the expandable controller is medically necessary. The Plan denied your request. The Plan says rules for coverage have not been met.
The Plan follows Medicare rules. Medicare rules say that expandable controllers are covered when 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 expandable controller for a power wheelchair. Our reviewer says that the expandable controller is not medically necessary. Our physician reviewer found the enrollee's upper limb strength and function are adequate for the member to be able to control the power options using their own switches. 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 expandable controller for a power wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller for a power wheelchair (E2377, E2313, E2311).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the services can be safely received in other settings, for example: a skilled nursing facility.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for congestive heart failure and was treated for a hematoma after cardiac catheterization Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 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-approve admission to an inpatient rehabilitation facility (IRF).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the brief emotional/behavioral assessment and domiciliary or rest home visit provided on December 15, 2020 by an OON provider.
You asked the Plan to pay for the brief emotional/behavioral assessment and domiciliary or rest home visit. You say that the services provided were medically necessary. The Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that prior authorization was not 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 had network providers available who could have provided 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 the brief emotional/behavioral assessment and domiciliary or rest home visit provided on December 15, 2020 by an OON provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ambulance trip provided by a participating provider on December 15, 2020.
You asked the Plan to waive the copayment for an ambulance trip. You say that you did not call the ambulance so you should not be responsible for this. The Plan denied your request. The Plan says the correct copayment has been applied.
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 $325 copayment for ambulance services. You have been asked to pay a $325 copayment for an ambulance trip. Since ambulance services were provided, the correct copayment has been applied. An ambulance trip falls within the ambulance services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an ambulance trip provided by a participating provider on December 15, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the SNF care provided from September 28, 2020, to October 30, 2020.
You asked the Plan to waive the copayment for SNF care. You say that you feel these services should be covered. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.
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 $0.00 copayment per day for days 1 to 20, and a $178.00 copayment per day for days 21 to 100 for Skilled Nursing Facility (SNF) care up to an in-network maximum out-of-pocket amount of $6,000 for 2020. At the time this claim was processed, $3,218.42 of the $6,000 in-network maximum out-of-pocket amount had been met. This SNF stay lasted 32 days, resulting in a total copayment amount of $2,781.58 because this amount, along with other cost-sharing amounts you have been asked to pay, met the $6,000 in-network maximum out-of-pocket amount for 2020. You have been asked to pay a $0.00 copayment per day for days 1 to 20, and a $178.00 copayment per day for days 21 to 100 for SNF care. SNF care falls within the Skilled Nursing Facility (SNF) care 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 SNF care provided from September 28, 2020, to October 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for supplies for a CPAP device provided on May 22, 2020, by an OON provider.
You asked the Plan to pay for CPAP supplies. You say that the requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.
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 had network providers available who could have provided 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 supplies for a CPAP device provided on May 22, 2020, by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cardiac Computed Tomography (CT) scan with calcium scoring (75571).
You asked the Plan to pre-approve the cardiac CT scan. You say that the CT scan is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
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 cardiac CT scan. Our reviewer says that the requested CT scan is not medically necessary. Our physician reviewer found Based on current American Heart Association guidelines, coronary calcium CT scanning can be indicated in asymptomatic intermediate cardiovascular risk patients who are being evaluated for risk factor modification and consideration of lipid lowering therapy. It would not be indicated as an appropriate or medically necessary study to rule out significant coronary artery disease in a patient complaining of chest pain symptoms. 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 cardiac CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a cardiac Computed Tomography (CT) scan with calcium scoring (75571).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab services provided on November 16, 2020.
You asked the Plan to waive the copayment for lab services. You say that the labs were part of your annual physical and you disagree with the charges. 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 tests. You received lab services on November 16, 2020. Lab services are not included in annual wellness exams and are subject to cost-sharing charges. Therefore, you are responsible to pay the $10 copayment. You have been asked to pay a $10 copayment for lab services. Lab 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 for lab services provided on November 16, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment testing provided on September 26, 2020.
You asked the Plan to pay for the cardiovascular risk assessment testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. Cardiovascular disease screening tests are only covered for certain indications.
The laboratory services at issue in this appeal were requested solely for screening purposes. While Medicare covers cardiovascular disease screening tests for certain indications, the documentation does not support that the enrollee met criteria for the services rendered. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment testing provided on September 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the digital hearing aids (V5261) purchased from an out-of-network provider on November 16, 2020.
You asked the Plan to pay for the hearing aids. You say that you needed new hearing aids and you were told to call a number to find an in-network provider. No one answered the phone, so you decided to get your hearing aids elsewhere. The Plan denied your request. The Plan says they can only cover hearing aids when they are provided by the in-network provider specified in the contract. You used an out-of-network provider, which is not covered for routine hearing services.
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. The Plan pays for hearing aids only when they are received from the Plan's specified hearing provider. We looked at the file and the Plan's rules. You did not purchase your hearing aids from the Plan's specified provider, as required by the contract. Routine hearing services and aids received from out-of-network providers are not covered. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the digital hearing aids (V5261) purchased from an out-of-network provider on November 16, 2020.