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

We decided that the Plan does not have to pre-approve a heavy-duty walker with seat attachment, bathtub wall
rail, and transfer bench.
You asked the Plan to pre-approve heavy-duty walker with seat attachment, grab bar, and transfer bench. You
say that you are appealing with records. The Plan denied your request. The Plan says the denial of authorization
for these items is correct, because the enrollee does not meet the criteria for the requested heavy-duty walker
and the bathtub wall rail and transfer bench are not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that heavy-duty walkers are only covered for
beneficiaries who weight over 300 pounds. Medicare rules say that bath seats/benches and grab bars are not
covered by Medicare.
We looked at the file and Medicare rules. The record does not show that the enrollee weighs over 300 pounds,
therefore the requested heavy-duty walker would not be covered by Medicare at this time. Based on this
information, we decided that Medicare rules for coverage of heavy-duty walker with seat attachment, grab bar,
and transfer bench have not been met. Therefore, we decided that the Plan does not have to pre-approve a
heavy-duty walker with seat attachment, bathtub wall rail, and transfer bench.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvewheelchair accessories for the enrollee.You asked the Planto pre-approvethe accessories. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is included in the payment to the SNF that the enrollee resides in.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home. Records show that the accessories is being requested for use in a SNF or hospital.Therefore, we decided that the Plandoes not haveto pre-approvewheelchair accessories for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approveCTA of the head.You asked the Plan to pre-approvethe scan. You say that this is medically necessary for the evaluation of lightheadedness. The Plan denied your request. The Plan says the records do not show a detailed exam done by the doctor.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 not medically reasonable or necessary. Our physician reviewer found the notes,including the treatment plan, mention the plan of obtaining a carotid ultrasound exam; that apparently has not been done and would provide important information. The physical exam does not include a detailed neurological examination especially of the brain stem and cerebellum. Absent such information, the medical necessity of the requested CTA of the head and neck has not yet been established.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 not been met.Therefore, we decided that the Plan does not have to pre-approveCTA of the head.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve MRI of the lower extremity for the enrollee.
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your request. The Plan says that the records do not show results of picture studies such as x-rays that show a reason for further imaging or did not find the source of the problem.
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that the requested MRI is medically reasonable and necessary. Our physician reviewer found it is noted that the enrollee has a chronic stage III ulceration to the left MPJ area, with x-rays evaluation demonstrating periosteal reaction. The physician has recommended an MRI to the left foot, to evaluate the fifth MPJ area for surgical intervention. Medicare advises that an MRI is covered when medically necessary and reasonable for the diagnosis or treatment of a specific patient involved. The recommended MRI to the left foot is reasonable and medically necessary to evaluate further any soft tissue and or bone changes that may facilitate surgical intervention for this enrollee. 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 MRI have been met. Therefore, we decided that the Plan has to pre-approve MRI of the lower extremity 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 to open the case again, we will send you a letter.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Armodafinil for the enrollee.
You asked the Plan to pre-approve this drug. The Plan denied your request. The Plan says that this is not covered under Part B.
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 Armodafinil for the enrollee.
Benefits for this drug 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora stress test provided on March 12, 2020.You asked the Plan to waive the copayment fora stress test. You say that you were told that you would only owe a $220 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 $275 copayment for each stress test. You have been asked to pay a $275 copayment for a stress test. A stress test falls 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 fora stress test provided on March 12, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve non-sterile gloves.
You asked the Plan to pre-approve non-sterile gloves. You say that you need non-sterile gloves and the Plan should supply them. The Plan denied your request. The Plan says non-sterile gloves are non-reusable disposable supplies.
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. Payment is packaged into payment for other services and no separate payment can be made. Therefore, we decided that the Plan does not have to pre-approve non-sterile gloves.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan coded 77014 provided on July 5, 2019.
You asked the Plan to pay for the CT scan. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 77014 is COMPUTED TOMOGRAPHY GUIDANCE FOR PLACEMENT OF RADIATION THERAPY FIELDS. We find that CPT code 77014 is not supported in the medical record. Specifically, this service was billed with an outpatient place of service and the date of service falls between the admission and discharge date of an inpatient confinement. Therefore, these services are considered to be performed in an inpatient setting and not in the outpatient setting. Based on this information, we decided that Medicare rules for coverage of the CT scan have not been met. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan coded 77014 provided on July 5, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lab services provided on September 27, 2019.You asked the Plan to pay forthe services provided. You say that you have serious issues that need to be investigated.The Plan denied your request. The Plan says you have other insurance that is primary.The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plancan direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer.The Plan has met its obligation with regards to coordination of benefits. As the secondary insurer, the Plan cannot be held responsible for the services provided until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay forthe lab services provided on September 27, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the FreeStyle Libre system and associated supplies.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the requirements were not met.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found you are noted to be a diabetic, who does not use insulin to treat his diabetes. There is no documentation (logs) of how often you test your blood glucose. There is no evidence that you use the results of blood glucose testing to self-adjust, self-administered insulin multiple times a day. As such, the documentation does not support that the use of a CGM is medically necessary and reasonable.
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 pre-approve the FreeStyle Libre system and associated supplies.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the train of four testing coded 95999 provided on November 12, 2019.
You asked the Plan to pay for the train of four testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 95999 is unlisted neurological or neuromuscular diagnostic procedure. We find that CPT code 95999 is not supported in the medical record. Specifically, this service (the train of four testing) is considered a bundled procedure as the cost is included in the cost of the primary procedure. Therefore, this code cannot be separately reimbursed. Based on this information, we decided that Medicare rules for coverage of the train of four testing have not been met. Therefore, we decided that the Plan does not have to pay for the train of four testing coded 95999 provided on November 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dermatology services to be provided by an out of
network (OON) provider.
You asked the Plan to pre-approve dermatology services. You say that you have not had any luck with the
providers you have seen. 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-approve
dermatology services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the medical services provided on October 8, 2019.
You asked the Plan to waive the copay for the services provided. You say that the services should be paid by the plan. The Plan denied your request. The Plan says the copays were 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 services fall within the physician services and outpatient diagnostic tests benefit categories. 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
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea shower chairand a raised toilet seat.You asked the Plan to pre-approvea shower chairand a raisedtoilet seat. You say that you would like to appeal the Plan's denial of the shower chair and raised toilet seat because you need the items.The Plan denied your request. The Plan says theseitems arenot a covered benefit.The Plan must follow Medicarerules. Medicare rules say that shower chairsand raised toilet seatsare not covered because they are not primarily medical in nature. While a shower chair and a raised toilet seat 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-approvea shower chairand a raised toilet seat.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on February 6, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. You say that the lab performed all the tests that were ordered by the referring physician. The Plan denied your request. The Plan says there is no network deficiency for these services, and alternate network providers were found.
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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these OON services. Therefore, we decided that the Plan does not have to pay for the lab services provided on February 6, 2020 by an out of network (OON) provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chiropractic services (98940, 99203).
You asked the Plan to pre-approve chiropractic services. You say that chiropractic treatments are the only thing that helps your pain. The Plan denied your request. The Plan says chiropractic services are covered only to treat subluxation.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. We looked at the file and Medicare rules. The file does not show that you have been diagnosed with subluxation. There is not documentation of a physical exam or an x-ray demonstrating a subluxation. Based on this information, we decided that Medicare rules for coverage of chiropractic services have not been met. Therefore, we decided that the Plan does not have to pre-approve chiropractic services (98940, 99203).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the two endosteal implants (D6010 x2). You asked the Plan to pre-approve the endosteal implants. You say that it is difficult for you to chew and your gums bleed. You also say that you have stomach issues from not being able to chew your food properly.The Plan denied your request. The Plan says this service is not a covered benefit.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, wedecided that the Plan does not have to pre-approvethe two endosteal implants (D6010 x2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for bone replacement graft for ridge preservation - per site
(D7953) provided on January 15, 2020 by an out-of-network provider.
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the
denied charges. The Plan denied your request. The Plan says the service is not a covered benefit under the 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, the requested items or services are not
among those covered under this benefit. This service is not listed in your EOC as a covered benefit; therefore, it
is not covered. Therefore, we decided that the Plan does not have to pay for bone replacement graft for ridge
preservation - per site (D7953) provided on January 15, 2020 by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the ultraviolet light therapy system (E0691).
You asked the Plan to pre-approve the ultraviolet light therapy system. You say that the enrollee has been diagnosed with eczema of the hands. To avoid starting biologic therapy and the fact that you do not currently offer in-office UV light treatment, you request reconsideration. The Plan denied your request. The Plan says this item is only covered for treatment of psoriasis and is therefore not covered.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ultraviolet light therapy system have not been met. Therefore, we decided that the Plan does not have to pre-approve the ultraviolet light therapy system (E0691).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
You asked the Plan to pre-approve the compression stockings. You say that the compression stockings should be covered for history of chronic ulceration and venous insufficiency. The Plan denied your request. The Plan says the compression stockings are noncovered.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the full leg pneumatic compressor device
provided from March 4, 2020.
You asked the Plan to waive the coinsurance for the full leg pneumatic compressor device. You say that you
were not told there was going to be a cost for the rental of this machine. You say you would like insurance to
pay this in full. 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 20%
coinsurance for durable medical equipment, oxygen/oxygen equipment and related supplies.
You have been asked to pay $147.28 which is 20% of the allowed amount for the full leg pneumatic
compressor device. The allowed amount is $736.46. ($736.46 x 20% = $147.28). The full leg pneumatic
compressor device falls within the "Durable medical equipment (DME) and related 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 coinsurance for the full leg pneumatic compressor device provided from
March 4, 2020.