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

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that you have tried shoe inserts from a medical supply store and they don't fit quite right. This leaves your feet hurting by the end of the day. You say that you believe your appeal was not reviewed correctly and asked the Plan to reevaluate your request. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient behavioral health services for enrollee.You asked the Plan to pre-approve continued services. You say that the enrollee is unable to complete is daily living activities on his own.The Plan denied your request. The Plan says there are no medical records to justify additional days.The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. The file shows that continued coverage beyond January 5, 2020 was requested for the enrollee. We looked at the file, and Medicare rules. Medicare rules say that providers must produce medical records showing why the lab services provided were medically necessary. In this case, there were insufficient records provided to show continued services would be used to determine a specific diagnosis or determine a specific treatment strategy for the enrollee. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient behavioral health services for enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in network rate forthe periodic oral evaluation (D0120), prophylaxis (D1110), the resin based composite for 3 surfaces on an anterior tooth (D2332), and the 2 resin based composites for 1 surface on an anterior tooth (D2330) provided from October 14, 2019 to October 21, 2019.You asked the Plan to pay the in network ratefor1 resin based composite for 1 surface on an anterior tooth. You say that you lost a filling from your tooth. You say that you were afraid the tooth would break. You also say that the services were emergent.The Plan denied your request. The Plansays 2 fillings per year are covered. The Plan also says that the frequency limit has been exceeded.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 fillings are a covered service, the frequency limit of 2 per calendar year has been exceeded. The Plan paid for 1 filling that you received on October 14, 2019 and 1 filling you received on October 21, 2019. Therefore, we decided that the Plan does not have to pay the in network rate forthe periodic oral evaluation (D0120), prophylaxis (D1110), the resin based composite for 3 surfaces on ananterior tooth (D2332), and the 2 resin based composites for 1 surface on an anterior tooth (D2330) provided from October 14, 2019 to October 21, 2019.
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 the records do not
show a need for the enrollee to be seen by a rehab doctor three times a week, and need an intensive team for
care.
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 the enrollee suffered a recent stroke and has mild residual right hemiparesis and impaired mobility. The
complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital
inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee is at moderate assist for
functional transfers and activities of daily living. The enrollee does 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forchiropractic services provided on October 7, 2019 by an out of network (OON) provider.You asked the Plan to pay forchiropractic services. You say that you have been going to this doctor for years.The Plan denied your request. The Plan says no prior authorization was obtained for these services. The Plan says that there are in-network providers available for these services.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 forchiropractic services provided on October 7, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the dental consultation (D9310) and the surgical extraction (D7210) to be provided by an oral surgeon.You asked the Plan to pre-approvethe dental services. You say that you were referred to an oral surgeon to have your broken teeth extracted.The Plan denied your request. The Plan says dental service provided by an oral surgeon are 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, dental services must be provided by a participating general dentist.Therefore, we decided that the Plan does not have to pre-approvethe dental consultation (D9310) and the surgical extraction (D7210) to be provided by an oral surgeon.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on October 13, 2019.
You asked the Plan to waive the copayment for the ambulance transport. You say that you should not be liable for the copay. The Plan denied your request. The Plan says that the cost share is a contractual obligation that you agreed to upon enrolling with the Plan.
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 $225 copayment for each Medicare-covered one-way trip in a ground ambulance. You have been asked to pay a $225 copayment for the ambulance transport. The ambulance transport falls within the Medicare-covered one-way trip in a ground ambulance 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 ambulance transport provided on October 13, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a Genecept Assay Test provided on September 26, 2019 by an out of network (OON) provider.
You asked the Plan to pay for a Genecept Assay Test. You say that this test was medically necessary. The Plan denied your request. The Plan says the referring provider is out-of-network. The Plan says that prior authorization was not obtained for this service.
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 a Genecept Assay Test provided on September 26, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the 2 surgical extractions (D7140) provided on January 9, 2019.You asked the Plan to reimburse you for the dental services. You say that your dentist retired. You say that you went to the provider for the extractions. You say that the services were approved by the Plan.The Plan denied your request. The Plan says extractions are not a covered service.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, extractions are not among those covered under this benefit.Therefore, we decided that the Plan does not have to reimburse you for the 2 surgical extractions (D7140) provided on January 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visits provided on September 18, 2019 and October 2, 2019.
You asked the Plan to waive the copayment for the office visits. You say that there were no invasive procedures performed. You say that errors were made. The Plan denied your request. The Plan says the copayments 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). Your contract with the Plan clearly says that you must pay a $45 copayment for provider and professional services at a specialist's office. You have been asked to pay a $45 copayment for each office visit. The total amount you owe is $90 ($45/visit x 2 visits = $90). The office visits fall within the "Physician/Practitioner services including doctor's office visits" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the office visits provided on September 18, 2019 and October 2, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a dental consultation (D9310) with the out of network provider.
You asked the Plan to pre-approve the dental service. You say that the enrollee has been a patient of the requested provider due to his special needs. The Plan denied your request. The Plan says the requested provider is not a network provider. The Plan says that dental services received out of network are not covered. The Plan also says that there are network providers available to provide the requested services.
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 service is not covered when you receive the service out of network. Therefore, we decided that the Plan does not have to pre-approve a dental consultation (D9310) with the out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (80156, 80157, 80177, 80201, 80162, 80159, and 80173) provided on May 7, 2019.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
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 80156, 80157, 80177, 80201, 80162, 80159, and 80173 are not supported in the medical record. Specifically, there is no laboratory report showing separate line item results for additional therapeutic drug levels and payment for these codes is included in the G0480 code, which was reimbursed. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services (80156, 80157, 80177, 80201, 80162, 80159, and 80173) provided on May 7, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe complete series of intraoral x-rays provided on October 30, 2019.You asked the Plan to pay forthe intraoral x-rays. You say that this procedure is required for heart surgery and hip surgery. You also say that as the patient you should not have to pay for a preventive procedure that is required per surgery requirements.The Plan denied your request. The Plan says this service is not a covered benefit per your dental benefits.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.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 pay forthe complete series of intraoral x-rays provided on October 30, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care provided on May 1, 2019.
You asked the Plan to pay for the initial hospital care. You say that the services that were performed in the hospital were emergent at the time of the enrollee's visit. 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 enrollee'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 the initial hospital care provided on May 1, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the patient continues to have high oxygen needs with high flow and humified mask and needs 3 weeks of antibiotics for pneumonia. He is significantly debilitated due to prolonged intubation and ICU hospital stay. The Plan denied your request. The Plan says The enrollee's medical condition appears stable. The enrollee does not have any complex wound care. There is no documentation of medical comorbidities/medical complexity to support the need for the availability of a rehabilitation physician on a 24/7 basis or face to face supervision by an inpatient rehabilitation physician 3 times a week, enrollee with no documentation of new onset focal neurologic deficits.
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 reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee presented to the ED on 2/1/2020 with shortness of breath and was admitted with acute respiratory failure due to pulmonary edema from congestive heart failure and pneumonia. He was minimally responsive due to CO2 narcosis and was intubated until 2/8/2020. Based on review of the available records, the enrollee does not meet criteria for IRF admission. The patient was medically stable with no evidence of need for supervision by PMR physician three times a week or acute rehab nursing care. He may benefit from further PT and OT but does not require an intensive therapy program as his functional level is very low at this time and will not be able to make a significant functional recovery in a predicted period of time 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve L3000 orthotics.
You asked the Plan to pre-approve the orthotics. You say that you need the custom orthotics. The Plan denied your request. The Plan says you do not have a diagnosis of diabetes and these orthotics are not part of an integral brace.
The Plan must follow Medicare rules. Medicare rules say that shoes, inserts, and modifications are covered in limited circumstances. They are covered in selected beneficiaries with diabetes for the prevention or treatment of diabetic foot ulcers. Inserts and other shoe modifications are covered if they are on a shoe that is an integral part of a covered brace and if they are medically necessary for the proper functioning of the brace. The Plan follows these same rules. We looked at the file and Medicare rules. Records show that you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Based on this information, we decided that Medicare rules for coverage of the orthotics have not been met. Therefore, we decided that the Plan does not have to pre-approve L3000 orthotics.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) services provided to the enrollee from March 29, 2019 through April 27, 2019.You asked the Plan to waive the copayment forthe SNF services. You say that  The Plan denied your request. The Plan says that co-payments are a member's contractual obligation.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 $100 copayment for per day, for days 21-100 of SNF care. The enrollee has been asked to pay a $900 copayment for the SNF services. The SNF services falls within the days 21-100 of SNF care 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 forthe skilled nursing facility (SNF) services provided to the enrollee from March 29, 2019 through April 27, 2019.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for eye refraction services (92015) provided on September 17, 2019.
You asked the Plan to pay for eye refraction services. You say that the provider is in network and your book of coverage benefits says there is no copay for routine eye exam with refraction up to one per year and this is the service you received. The Plan denied your request. The Plan says that eye refraction services is not covered by the plan and that Medicare covered vision services has a $40 copayment.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when 1 routine eye exam (includes refraction) is covered with $0 copay. We looked at the file and the Plan's rules. The plan's evidence of coverage specifically says on page 86 that routine eye exam, including refraction is covered with $0 copay once a year. The explanation of benefits and records provided also shows that the servicing provider is a participating provider. Based on this information, we decided that the Plan's rules for coverage of eye refraction services have been met. Therefore, we decided that the Plan has to pay for eye refraction services (92015) provided on September 17, 2019.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a dentoalveolar procedure.
You asked the Plan to pre-approve the dentoalveolar procedure. You say that this service is the last piece in the reconstruction of your jaw after beating cancer. The Plan denied your request. The Plan says this service is excluded from coverage under your plan.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve a dentoalveolar procedure.