Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.  You asked the Plan to pre-approve the LTACH services. You say that you disagree with the denial. The Plan
denied your request. The Plan says the services are 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 services are not medically necessary. Our physician reviewer found the enrollee is currently
undergoing treatment at an acute care hospital (ACH) for a recurrent perirectal abscess. The enrollee has
undergone surgical drainage of the abscess. The enrollee's continues to receive wound care and antibiotics. The
enrollee is not intubated/ventilated. As LTACHs and ACHs are licensed to provide the same level of care, there
is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until
such time no acute services are required.
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 for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve12 additional physical therapy (PT) visits (97164) .You asked the Plan to pre-approve12 additional PT visits. You say that the services are necessary.The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.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 12 additional PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found in this case, there is no indication prior PT has served to provide sustained, significant improvement in pain and/or function and there are no indications that residual deficits could not be addressed via a home exercise program. The services 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 12 additional PT visits have not been met.Therefore, we decided that the Plan does not have to pre-approve12 additional physical therapy (PT) visits (97164)
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that the enrollee is totally bedridden. You say that the enrollee's daughter is worried that the enrollee will fall and suffer injuries. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on July 9, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
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 physician's services provided on July 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Flu Zone High-Dose vaccine.
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 vaccine is not covered.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide these services. The Plan follows the same rules. The services at issue are a high dosage flu shot. This vaccine is not covered by Medicare or the Plan. The Plan covers a standard dose flu shot once each flu season in the fall or winter. Therefore, we decided that the Plan does not have to pre-approve a Flu Zone High-Dose vaccine.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre approve a pneumatic compression device (E0652). You asked the Plan to pre approvea pneumatic compression device. You say that the enrollee requires the device.The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic pump that Medicare requires.The Plan follows Medicare rules.The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.Therefore, we decided that the Plan does not have to pre approve a pneumatic compression device (E0652).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids provided by an out-of-network provider on October 31, 2018.
You asked the Plan to pay for the hearing aids. You say that you are requesting reimbursement of services rendered. The Plan denied your request. The Plan says you self-referred to this out-of-network provider.
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. The provider is out-of-network with the Plan. Your EOC clearly states, enrollees must pay a maximum of $350 towards the cost of 1 non-implantable hearing aid(s) every year. Benefit includes a 1-year standard warranty and 1 package of batteries. Any cost above $350 and 1 hearing aid is the member's responsibility and additional hearing aids are not covered. Routine hearing services must be received from a participating provider in order to be covered by the plan. For out-of-network hearing aids you pay 50% of the cost for 1 hearing aid(s) every year. Therefore, we decided that the Plan does not have to pay for hearing aids provided by an out-of-network provider on October 31, 2018.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance transport provided on August 6, 2019 by out of network provider, Ambulnz NY.You asked the Plan to pay for the ambulance transport. The Plan denied your request. The Plan says that 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-networkproviders 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 for the ambulance transport provided on August 6, 2019 by out of network provider, Ambulnz NY.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Dexamethasone 4mg tablet medication.
You asked the Plan to pre-approve this medication. You say that you are requesting reconsideration of the plan's denial. The Plan denied your request. The Plan says this medication is not a covered benefit under the member's policy as the medication is not a full therapeutic replacement for intravenous anti-emetic therapy that would have been administered at the time of the chemotherapy treatment.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve the Dexamethasone 4mg tablet medication.
Benefits for this medication 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for vision services provided by an in-network provider on August 7, 2019.You asked the Plan to waive the copayment forvision services. You say that you feel you should not be liable for the cost-share due to thinking the services were covered.The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). You received a non-routine eye exam on date of service August 7, 2019 from an in-network provider. Therefore, you are asked to pay a $35 copayment for the eye exam. 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 vision services provided by an in-network provider on August 7, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.You asked the Plan to pre-approve SNF care. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are identifiable skilled nursing service needs and skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.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 care have not been met.Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar orthosis provided to the enrollee on August 29, 2019.
You asked the Plan to pay for the orthosis. You say that this item was medically necessary. The Plan denied your request. The Plan says that there is no proof of delivery.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain proof of delivery for the supplies provided in this case. Therefore, we decided that the Plan does not have to pay for the lumbar orthosis provided to the enrollee on August 29, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650) provided to the enrollee on August 22, 2019.You asked the Plan to pay for the orthosis. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order; therefore, the billed service cannot be verified.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid physician order or proof of delivery for the supplies provided in this case. There was no itemized shipping order so the supplies cannot be verified. Therefore, we decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650) provided to the enrollee on August 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second opinion to be provided by out of network
(OON) facial nerve specialist.
You asked the Plan to pre-approve the OON second opinion consultation. You say that you were referred to an OON provider for evaluation of your Bell's palsy. You feel that you should be allowed to see the OON who is the
only facial nerve surgeon in the area because you want to ensure that you have the correct diagnosis and are
being given the best treatment. The Plan denied your request. The Plan says it is not clear that the expertise of
facial nerve surgeon is required; however, the plan's network does have two providers with this expertise who
can provide a second opinion. There are physicians at an in network Medical Center that
have this type of expertise.
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 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. 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
a second opinion to be provided by out of network (OON) facial nerve specialist.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for SNF care provided by an in-network provider from May 1, 2019 through May 16, 2019.
You asked the Plan to waive the copayment for SNF care. You say that the doctor said you had to stay until you were discharged. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received SNF care provided by an in-network provider from May 1, 2019 through May 16, 2019. From April 24, 2019 through April 30, 2019 there was no copayment due. For dates May 1, 2019 through May 16, 2019 you were asked to pay 50% coinsurance per day for SNF care. Therefore, you are responsible for $361.21. 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 SNF care provided by an in-network provider from May 1, 2019 through May 16, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for oxygen concentrator, single delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate (CPT Code E1390) purchased from an out-of-network provider on April 15, 2019.
You asked the Plan to pay for the DME. You say that you are requesting reimbursement of services rendered. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. The plan has determined that the denial of reimbursement for the portable oxygen concentrator you purchased on April 15, 2019 is correct. Only rented oxygen equipment is eligible for coverage. Purchased oxygen equipment is statutorily non-covered. Therefore, we decided that the Plan does not have to pay for oxygen concentrator, single delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate (CPT Code E1390) purchased from an out-of-network provider on April 15, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services for a central motor evoked potential study and a continuous intraoperative neurophysiology monitoring provided on November 25, 2018.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare-covered services related or unrelated to the member's terminal condition.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's services for a central motor evoked potential study and a continuous intraoperative neurophysiology monitoring provided on November 25, 2018.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia 60 MG/ML syringe.You asked the Plan to pre-approve Prolia. You say that the requested Prolia is medically necessary.The Plan denied your request. The Plan says the enrollee must try and fail the preferred drug, Zoledronic acid first.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.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 Prolia. Our reviewer says that the Plan's step therapy criteria have not been met. Our physician reviewer found the enrollee is with a diagnosis of age-related osteoporosis without current pathological fracture. The submitted Bone Density Report dated 6/27/2014 documents osteopenia.The Plan requires a trial of Zoledronic acid first before they will approve the requested drug, Prolia. Based on the documentation provided, the enrollee has not tried and failed the required drug, Zoledronic acid first. The available documentation does not support that Zoledronic acid would likely be less effective, and/or would likely have adverse effects for the enrollee in this case.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met.Therefore, we decided that the Plan does not have to pre-approve Prolia 60 MG/ML syringe.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services provided on May 22, 2019.You asked the Plan to pay for the ambulance services. You say that the enrollee was not admitted to hospice until May 29, 2019.The Plan denied your request. The Plan says Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.The enrollee ended Medicare Hospice benefits on May 1, 2019. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for ambulance services provided on May 22, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that you woke up and felt dizzy and nauseous. You called an ambulance and the responders arrived and treated you. You say that by the time they had left, your dizziness had subsided. Because you were alone and frightened, you say that the Plan should reconsider the claim. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on June 25, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services.