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

We decided that the Plan does not have to pre-approve a continuous glucose monitor.
You asked the Plan to pre-approve a continuous glucose monitor. You say that you want a continuous glucose monitoring system so your family can check your levels and you have a hard time finger stick testing. The Plan denied your request. The Plan says criteria for a CGM is not met.
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. The record shows you do not test four or more times a day and you are not insulin treated. Based on this information, we decided that Medicare rules for coverage of a continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic radiology provided on January 25, 2020.
You asked the Plan to pay for the diagnostic radiology. The Plan denied your request. The Plan says nonemergent,
non-urgent services with out-of-network providers require prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
service 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 diagnostic radiology provided on January 25, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on December 30, 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 a physician order is not required to be signed, however, the physician must clearly document, in the medical record, his or her intent that the test be performed.We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regards to the physician's intent that the test be performed prior to services taking place.Therefore, we decided that the Plan does not have to pay for the laboratory services provided on December 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on February 14, 2020 by an out of network (OON) provider.
You asked the Plan to pay for these medical services. 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 payable.
The rules say that Medicare pays for services only when they are furnished by a provider or supplier enrolled in the Medicare program. Review of the file shows that the provider of these services was not Medicare-certified for the date of service 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 medical services provided on February 14, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on January 15, 2020.
You asked the Plan to waive the copayment for the specialist office visit. You say that you had a brief visit and a hearing test and that you should have no charge for this visit. 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 $45 copayment for services obtained from a specialist, or under certain circumstances, treatment by a nurse practitioner or physician's assistant or other non-physician health care professionals in a specialist's office. You have been asked to pay a $45 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows you were charged for the specialist office visit. The record also shows the hearing test applied a $0 copayment on a separate claim.
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 specialist office visit provided on January 15, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide routine transportation trips, to an oral surgeon, exceeding 60 miles.
You asked the Plan to provide routine transportation trips exceeding 60 miles. You say that you need transportation to an oral surgeon for extractions so that you can get a surgery. The Plan denied your request. The Plan says each one-way trip must not exceed 60 miles.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers routine transportation trips that do not exceed 60 miles based on the most efficient route. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to provide routine transportation trips, to an oral surgeon, exceeding 60 miles.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on March 23, 2020.
You asked the Plan to waive the copayment for the ambulance transport. You say that you were admitted after the EMS dropped you off. You say that you shouldn't have to pay the copayment. The Plan denied your request. The Plan says the copayment 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 $270 copayment for Medicare-covered ambulance benefits. You have been asked to pay a $270 copayment for the ambulance transport. The ambulance transport falls within the "Ambulance services" benefit category. The records show that you were transported by ambulance to the hospital. 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 March 23, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to provide a tier exception for Orthovisc 15mg/ml syringes. 
 
You asked the Plan to provide a tier exception for orthovisc. You say that a tier exception is needed for the medication. The Plan denied your request. The Plan says this drug is not eligible for a tier exception. 
 
The Plan must follow Medicare rules. Medicare rules say that Tier exceptions can be granted for some Part D drugs.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for a tier exception have not been met. Specifically, Orthovisc is a Medicare Part B Prescription Drug. Part B Drugs are not eligible for a tier exception. Therefore, we decided that the Plan does not have to provide a tier exception for Orthovisc 15mg/ml syringes
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the compression stockings identified with code A6549 that were issued on December 11, 2019.
You asked the Plan to pay for the compression stockings. You say that you require the stockings to treat lymphedema related to a breast cancer diagnosis. The Plan denied your request. The Plan says the compression stockings are a non-covered benefit.
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6549 are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound.
The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you do not have a medical condition for which compression stockings can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the compression stockings identified with code A6549 that were issued on December 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the glucose monitor and supplies provided on February 11, 2020.
You asked the Plan to waive the coinsurance for the glucose monitor and supplies. You say that your supplies should be covered 100%. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for diabetic supplies and therapeutic shoes. You have been asked to pay $49.68, which is 20% of the allowed amount for the glucose monitor and supplies. The allowed amount is $248.38 (20% x $248.38 = $49.68). The glucose monitor and supplies falls within the "Diabetes self-management training, diabetic 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 coinsurance for the glucose monitor and supplies provided on February 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral exam (D0120) extraction, tooth 12 (D7140) partial upper denture (D5213) and intraoral-periapical first x-ray (D0220) provided September 10, 2019 to October 14, 2019.
You asked the Plan to pay for the dental services. You say that you were told by a plan representative that this provider was in-network. You had an emergency as your tooth broke and it was very painful. The Plan denied your request. The Plan says enrollee's must receive their services from an in-network provider. Non-emergent services with non-contracted providers require prior-authorization prior to services being rendered.
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 for the periodic oral exam (D0120) extraction, tooth 12 (D7140) partial upper denture (D5213) and intraoral-periapical first x-ray (D0220) provided September 10, 2019 to October 14, 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 enrollee does not have complex medical needs, and does not need three hours per day of therapy. 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 is generally medically stable. There is no evidence of complex medical issues that require monitoring by an inpatient rehab physician three times per week or need for acute rehab nursing care. Currently the enrollee is at a moderate to maximum assist level for mobility and activities of daily living. While the enrollee may benefit from continuing physical, occupational, and speech therapy, there is no evidence of need for an intensive therapy program with therapy 3 hours per day at the current level of progress with frequent physician oversight and an interdisciplinary approach to rehabilitation care. He will not make any more significant functional progress in an IRF in a perceivable period of 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 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on January 7, 2020.You asked the Plan to waive the copayment for ambulance services. You say that you were told that you would not owe a copayment because you were being transferred to another hospital.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 $300 copayment for ambulance services. You have been asked to pay the allowed amount of $236.62, which is less than the $300 copayment for ambulance services. Ambulance services fall within the ambulance services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment for ambulance services provided on January 7, 2020.
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 you require the compression stockings. The Plan denied your request. The Plan says you do not have a qualifying wound.
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6530 are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound. The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you do not have a medical condition for which compression stockings can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional mileage for routine transportation for a total of 72 miles per one-way trip.
You asked the Plan to pre-approve additional mileage. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services exceed the benefit limit.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers routine transportation when each one-way trip does not exceed 50 miles. We looked at your request, the records in the case file, and the rules. Review of the file shows that you are requesting routine transportation for 72 miles per one-way trip. This exceeds the 50-mile one-way trip limit. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve additional mileage for routine transportation for a total of 72 miles per one-way trip.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on October 22, 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 a physician order is not required to be signed, however, the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regards to the physician's intent that the test be performed prior to services taking place. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on October 22, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar epidural injections.
You asked the Plan to pre-approve the requested injections. You say that pain is affecting the enrollee's quality of life. The Plan denied your request. The Plan says the enrollee does not have imaging studies that show central disc herniation, severe degenerative disc disease, or central spinal stenosis.
The Plan follows Medicare rules. Medicare rules say that lumbar epidural injections are only covered under certain medical indications. 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 requested injections. Our physician reviewer found that the enrollee has a diagnosis of low back pain with radiation down her leg. The enrollee received a facet joint injection on June 1, 2020, that provided 50% relief. However, by June 12, 2020, she was experiencing only 20% relief. While the enrollee does have low back pain with a pain score of 3-7/10, she does not have imaging studies that show central disc herniation, or severe degenerative disc disease or central spinal stenosis. Based on the rules and records provided, the enrollee does not meet the coverage criteria for the requested lumbar epidural steroid injection. 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 requested injections have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar epidural injections.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ozurdex (J7312). You asked the Plan to pre-approve Ozurdex. You say that this is medically necessary. The Plan denied your request. The Plan says this use of the drug is experimental. The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Ozurdex. Our reviewer says that the use of Ozurdex is not supported in this case. Our physician reviewer found Ozurdex is not FDA-approved for the treatment of chronic chorioretinal inflammation. The use of Ozurdex for this diagnosis is not supported in the compendia. The documentation does not support that Ozurdex is medically reasonable and necessary 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 Ozurdex have not been met. Therefore, we decided that the Plan does not have to pre-approve Ozurdex (J7312).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on February 23, 2020.
You asked the Plan to pay for the ambulance services. You say that the claim should be covered. The Plan denied your request. The Plan says the ambulance services were not reasonable and medically necessary.
Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules. 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 pay for the ambulance services. Our reviewer says that the service was not medically necessary. Our physician reviewer found based on the medical records provided the enrollee's presenting symptoms did not meet prudent layperson criteria for emergency care. The documentation does not support that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated for this enrollee. The documentation does not support that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped ambulance can provide for safe transport. The ambulance transport was not medically reasonable and necessary for the 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 ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on February 23, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on March
18, 2020.
You asked the Plan to waive the copayment for the ambulance transport. You say that you weren't informed a
private ambulance would be coming or that it would result in a copayment. The Plan denied your request. The
Plan says the copayment 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 $395
copayment for each Medicare-covered one-way trip by ground ambulance.
You have been asked to pay a $395 copayment for the ambulance transport. The ambulance transport falls
within the "Ambulance services" benefit category. This means that you have been asked to pay the correct
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for
the ambulance transport provided on March 18, 2020.