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

We decided that the Plan does not have to pre-approve wheelchair accessories (transfer handles, expandable controller, harness, electrical connection) for the enrollee.
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied your request. The Plan says the accessories cannot be covered as it is not medically necessary to control the three approved power options through the joystick (drive interface).
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 accessories. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is not medically necessary above a standard device, with standard accessories. The remaining requests including harness and transfer handles are convenience items and will not serve to markedly enhance PMD function or enrollee ability to participate in MRADL's.
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 accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve wheelchair accessories (transfer handles, expandable controller, harness, electrical connection) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Trelegy Ellipta inhaler.You asked the Planto pre-approve the Trelegy Ellipta. You say that this is necessary for the enrollee's COPD.The Plan denied your request. The Plan says this self-administered medication is not covered by Medicare 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 the Trelegy Ellipta inhaler.Benefits for the Trelegy Ellipta 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 copayments for the specialist office visit or the hearing test provided on May 20, 2019.
You asked the Plan to waive the copayments for the specialist office visit and the hearing test. You say that you were charged a $50 copayment and is now being responsible for an additional $50 copayment. 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 for each covered specialist office visit and a $50 copayment for each Medicare-covered hearing exam to determine if you need medical treatment for a hearing condition. You have been asked to pay a $50 copayment for the specialist office visit and a $50 copayment for the hearing test. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The hearing test falls within the "Hearing services - Medicare-covered" 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 copayments for the specialist office visit and hearing test provided on May 20, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve comprehensive exam x4 (D0150) dental implants x5 (D6010) and dental extractions x5 (D7140).
You asked the Plan to pre-approve the dental services. You say that without the alternative treatment of dental implants the enrollee would be at risk for chocking, losing, oxygen and being placed on a respirator. The Plan denied your request. The Plan says comprehensive exam is covered once every 3 years, therefore the plan approved for 1 comprehensive exam. The additional requests are not listed under the plan benefits and is therefore not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve comprehensive exam x4 (D0150) dental implants x5 (D6010) and dental extractions x5 (D7140).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90832) provided on July 31, 2019.
You asked the Plan to pay for the psychotherapy services. You say that the provided services were medically necessary and rendered in good faith. The Plan denied your request. The Plan says with the information submitted, the Plan was unable to determine if a physician's order was given, how the member came to the servicing provider or whether the services were medically necessary.
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the psychotherapy services have not been met. Specifically, no medical records were submitted to determine whether payment is due and the amount of payment. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90832) provided on July 31, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the full amount for the periodic oral evaluation (D0120), prophylaxis (D1110), and the bitewing x-ray (D0274) provided from July 9, 2019 to July 24, 2019 by out of network dentist.
You asked the Plan to pay the full amount for the dental services. You say that you called the Plan prior to your appointment. You say that you were advised by a Plan representative that x-rays were covered. You say that you were not advised of the difference in coverage for the in network and out of network providers. The Plan denied your request. The Plan says the services you received are covered. The Plan also says the claims have been reprocessed at the in network rate. The Plan has confirmed you are now only being charged the amount above the Medicare allowed amounts.
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 and the services you received are listed as covered, you received the services out of network. The record shows the Plan reprocessed your claims at the in network rates. Although you do not owe any copayments, the Evidence of Coverage clearly says the you are responsible for any billed amounts that are above the Medicare allowed amount. This is a contractual obligation you agreed to when you enrolled in the Plan's dental coverage. Therefore, we decided that the Plan does not have to pay the full amount for the periodic oral evaluation (D0120), prophylaxis (D1110), and the bitewing x-ray (D0274) provided from July 9, 2019 to July 24, 2019 by out of network dentist.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve QVAR Redihaler for the enrollee.
You asked the Plan to pre-approve QVAR. You say that the enrollee has been well-controlled on QVAR. The Plan denied your request. The Plan says drug coverage is limited to Medicare Part B covered drugs.
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 QVAR Redihaler for the enrollee.
Benefits for QVAR 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 pay for physician's services provided on July 26, 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, 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 26, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveLTACH services.You asked the Plan to pre-approvethe LTACH services. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care and doesnot require transfer.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 physician reviewer found that in the case of this enrollee, they were admitted to the current acute care hospital following hysterectomy with lymph node dissection for high grade serous carcinoma of the endometrium. However, the stay was complicated by acute kidney failure, aortic injury with bleeding, pulmonary embolism, and respiratory failure requiring mechanical ventilation as well as hypotension, requiring pressors. Wound care for the post-operative wound was needed. Recent notes reveal a gradual improvement. Based on the clinical course and recent changes, although ongoing acute care is warranted, it is not likely the enrolleewould require prolonged acute care beyond 25 days. The proposed treatment at the LTACH would not be materially different from the currently provided acute care. Therefore, this request for LTACH transfer 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 LTACH services have not been met.Therefore, we decided that thePlan does not have to pre-approvelong term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance the Part B injection provided on July 15, 2019.
You asked the Plan to waive the coinsurance the Part B injection. You say that you have never had to pay over $10 for the injection. You say your primary care doctor said you would not have to pay for it. 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 Medicare Part B chemotherapy and non-chemotherapy prescription drugs. You have been asked to pay $229.20 which is 20% of the allowed amount for the Part B injection. The allowed amount is $1,146. ($1,146 x 20% = $229.20). The Part B injection falls within the "Medicare Part B prescription drugs" 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 the Part B injection provided on July 15, 2019.
Our decision is only about the July 15, 2019 service. If you have any questions about prior years billing, please contact the plan directly.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal evaluation (D0180) and the periodontal maintenance (D4910) provided on August 26, 2019.
You asked the Plan to pay for the dental services. You say that you were advised by a Plan representative that the services would be covered. You also say you were advised that your responsibility was 50% for out of network providers. The Plan denied your request. The Plan says the services you received are 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 dental services you received are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the periodontal evaluation (D0180) and the periodontal maintenance (D4910) provided on August 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power mobility device.
You asked the Plan to pre-approve a power mobility device. You say that you need a power mobility device to go shopping and get around your complex, store and park. The Plan denied your request. The Plan says you do not have a safe place to store, secure, and charge the equipment and your assessment shows you are able to use a manual wheelchair.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The file shows that you do not have a mobility deficit that impairs your participation in MRADLs and your condition can be improved by a walker, cane or manual wheelchair. This means that Medicare rules for coverage of a PMD have not been met. Also, the item at issue in this appeal is being requested for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan cover PMDs for use only outside the home. Therefore, we decided that the Plan does not have to pre-approve a power mobility device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says you do not need therapy 3 hours a day, or to be seen by a rehab doctor three times a week.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found that you have a history of rheumatoid arthritis and Parkinson's disease, along with chronic neck pain that has failed reasonable conservative care. Imaging revealed significant spondylosis and you underwent a C3-T fusion. Pain is controlled and hemodynamics, as well as neurological functioning is intact/stable. 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 are at a minimal to maximum assist level for functional transfers and activities of daily living. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental extractions.You asked the Plan to pre-approve dental extractions. You say that you cannot afford to pay for the extractions.The Plan denied your request. The Plansays your benefit has been exhausted for the plan year.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 file shows that 21 dental extractions were requested. The plan has agreed to pre-approve 3 extractions. We looked at the file, and Medicare rules. Your plan only covers 3 extractions per calendar year. Based on this information, we decided that the Plan's rules for coverage have not been met.Therefore, we decided that the Plan does not have to pre-approveadditional dental extractions.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services provided on October 11, 2019 to October 19, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the chiropractic services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received are not a covered benefit when provided by an out-of-network provider.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the chiropractic services provided on October 11, 2019 to October 19, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing rendered on July 22, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay forthe drug testing rendered on July 22, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the imaging services (72100, 73502, and 74176) provided on August 14, 2019 by an out of network (OON) provider.
You asked the Plan to pay for imaging services. You say that these services were medically necessary. The Plan denied your request. The Plan says these services were not authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the imaging services (72100, 73502, and 74176) provided on August 14, 2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for suction assisted lipectomy (15877 and 15879) provided on July 29, 2019.
You asked the Plan to pay for the suction assisted lipectomy. You say that you consulted a plastic surgeon and were told that liposuction could remove the fluid that resulted from your condition and restore you to a more natural anatomical figure. The Plan denied your request. The Plan says this service is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at your request, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the suction assisted lipectomy have not been met. Specifically, Per Local Coverage Article: Billing and Coding: Non-covered Services other than CPT Category III Non-covered Services (A56506), CPT codes 15877 and 15879 for lipectomy are non-covered as they are not medically reasonable and necessary. Therefore, we decided that the Plan does not have to pay for suction assisted lipectomy (15877 and 15879) provided on July 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99214) provided on June 4, 2018.You asked the Plan to pay for the office visit. You say that you would like reconsideration as this claim was submitted timely. The Plan denied your request. The Plan says this claim was not received within 12 months or 1 calendar year from the date when the services were rendered.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service.The record shows that a claim for the office visit was not filed until August 29, 2019. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for an office visit (99214) provided on June 4, 2018.