Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered to the enrollee on July 21, 2018.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was not filed timely.
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 these services was not filed until November 20, 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 the services rendered to the enrollee on July 21, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe knee orthoses and suspension sleeves provided on November 11, 2019.You asked the Plan to pay forthe knee orthoses (L1833) and suspension sleeves (L2397). You say that the orthoses were medically necessary.The Plan denied your request. The Plan says the documentation submitted did not support medical necessity for the orthoses.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 progress notes do not mention a need for the knee orthoses. Based on this information, we decided that Medicare rules for coverage of the knee orthoses (L1833) and suspension sleeves (L2397) have not been met.Therefore, we decided that the Plan does not have to pay forthe knee orthoses and suspension sleeves provided on November 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 6, 2019 by an out of network (OON) provider.
You asked the Plan to pay for office visit. You say that you are appealing with records that support the need for service. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and prior 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-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 medical services provided on September 6, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lumbar-sacral orthosis provided on December 20, 2019.You asked the Plan to pay forthe lumbar-sacral orthosis (L0650). You say that the orthosis was medically necessary.The Plan denied your request. The Plan says the enrollee haslumbar-sacral orthoses (L0650) received from different providersin 2016, 2017, and 2018that arestill under reasonable useful lifetime.The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary.The enrollee's current orthoses arestill within the 5-year RUL and the documentation submitted does not show that the orthoses areirreparably worn, irreparably damaged, or that the enrollee had a change in medical condition to warrant the lumbar-sacral orthosis at issue. Based on the records provided, there is no indication the orthoses provided met Medicare coverage criteria for replacement at the time of issue. Medicare coverage criteria for orthoses replacement were not met.Therefore, we decided that the Plan does not have to pay forthe lumbar-sacral orthosis provided on December 20,2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist visit rendered to you on April
5, 2019. You asked the Plan to waive the copayment for these services. You say that you were inpatient at the time. The
Plan denied your request. The Plan says the copayment was 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 $15
copayment for each covered visit or consultation in an outpatient location with a specialist.
Review of the file shows that you had an outpatient specialist visit on April 5, 2019. You have been asked to
pay a $15 copayment for these services. These services fall within the covered visit or consultation in an
outpatient location with a specialist 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 specialist visit rendered to you on April 5, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve outpatient hospital dental services for the enrollee.
You asked the Plan to pre-approve the dental services. You say that this is medically necessary. The Plan
denied your request. The Plan says the hospitalization or non-hospitalization of a patient has no direct bearing
on the coverage or exclusion of a given dental procedure.
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 outpatient hospital
dental services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea semi-electric hospital bed and innerspring mattress.You asked the Plan to pre-approvea semi-electric hospital bed (E0261) and mattress (E0271). You say that  The Plan denied your request. The Plan says there is no documentation the enrollee is unable to change positions in bed or has an immediate need to change positions in bed.The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed (E0261) may be considered medically necessary when the patient:1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or2. Requires attachments which can only be attached to a hospital bed; AND3. Requires frequent changes in body position and/or has an immediate need for a change in body position.We looked at the file and Medicare rules.The records do not support a need for frequent or immediate change in body position.Based on this information, we decided that Medicare rules for coverage of a semi-electric hospital bed and mattress have not been met.Therefore, we decided that the Plan does not have to pre-approvea semi-electric hospital bed and innerspring mattress.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the ambulance transport provided on August 2, 2019.
You asked the Plan to waive the copay for the ambulance transport. The Plan denied your request. The Plan says that the copay 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 $100 copay for Medicare-covered ambulance services. You have been asked to pay a $100 copay for the ambulance transport. The ambulance transport falls within the Medicare-covered 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 copay for the ambulance transport provided on August 2, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213).
You asked the Plan to pre-approve the maxillary partial denture. You say that the maxillary partial denture would be a different option for the enrollee to move forward with. The Plan denied your request. The Plan says this service exceeds the maximum count allowed per period.
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, upper partial dentures (D5213) are limited to one procedure every five plan years. The record shows that the enrollee received a maxillary partial denture on February 13, 2019 and the enrollee's partial denture benefit is now exhausted. Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture (D5213).
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Brovana. 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 step therapy requirement is not met. 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records show that you have chronic obstructive pulmonary disease (COPD). You have not tried and failed the plan's required drug of Perforomist. The records do not show that the required drug would be less effective or have adverse effects; therefore, the requested Brovana is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Brovana.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second enhanced annual visit.
You asked the Plan to pre-approve the visit. You say that you were not happy with the service received during
the first visit. The Plan denied your request. The Plan says a second visit is not covered.
The Plan must follow Medicare rules. Plan rules state that annual visits can only be covered once per year.
You already received this service this year, on February 3, 2020. Based on this information, we decided that
Medicare rules for coverage of the visit have not been met. Therefore, we decided that the Plan does not have
to pre-approve a second enhanced annual visit.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide wheelchair van transportation to an appointment.
You asked the Plan to provide wheelchair van transportation. You say that you need transportation to an
appointment for a procedure. The Plan denied your request. The Plan says a wheelchair van transport is not
reasonable and medically necessary to safely transport you to your medical appointment.
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 wheelchair transportation when medically appropriate.
We looked at your request, the records in the case file, and the rules. There is no documentation you cannot get
into a private car for transport. Based on this information, we decided that the Plan's rules for coverage of
wheelchair transportation have not been met. Therefore, we decided that the Plan does not have to provide
wheelchair van transportation to an appointment.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve18 surgical extractions (D7210) and general anesthesia (D9222) to be provided in a hospital setting by an oral surgeon.You asked the Plan to pre-approve the dental services. You say that you need the teeth surgically removed because there are only roots left below the gum line. You say that you have been seen by a general dentist who advised that you need to have your remaining teeth extracted by an oral surgeon since the roots are still intact.The Plan denied your request. The Plan says dental services must be provided by a participating general dentist in order to be 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 and extractions are a covered service, dental services must be provided by a participating general dentist in order to be covered. Additionally, there is no evidence that you have seen an oral surgeon in order to determine the appropriate treatment plan.Therefore, we decided that the Plan does not have to pre-approve18 surgical extractions (D7210) and general anesthesia (D9222) to be provided in a hospital setting by an oral surgeon.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a hot tub.You asked the Plan to pre-approve a hot tub. You say that you have low back pain and a hot tub would help circulate your blood and help you heal.The Plan denied your request. The Plan says hot tubs are not durable medical equipment by Medicare guidelines.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plan does not have to pre-approve a hot tub
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair power seat elevation feature.
You asked the Plan to pre-approve a power wheelchair power seat elevation feature. You say that the power wheelchair power seat elevation feature is necessary for the enrollee to complete MRADLs. The Plan denied your request. The Plan says seat elevation features are not covered by Medicare or the Plan.
The Plan must follow Medicare rules. Medicare rules say options and accessories for wheelchairs are covered if the beneficiary has a wheelchair that meets Medicare coverage criteria and the option/accessory itself is medically necessary. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair power seat elevation feature.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on October 21, 2019.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergencysituation, has been documented. 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 thePlan. The Plan did not pre-approve the servicesat 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 October 21, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for massage therapy received from November 25, 2019 to December 2, 2019.You asked the Plan to pay forthe therapy. You say that this is medically necessary.The Plan denied your request. The Plan says the enrollee has exhausted their benefit for this type of service.The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. The plan does cover 10 visits per year as a supplemental benefit. This benefit has been exhausted, so the visits at issue in this case cannot be covered.Therefore, we decided that the Plan does not have to pay for massage therapy received from November 25, 2019 to December 2, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a walk-in tub.
You asked the Plan to pre-approve a walk-in tub. You say that because of your medical conditions you cannot
get into your tub and this prevents you from performing good hygiene. The Plan denied your request. The Plan
says walk-n tubs are convenience, hygienic items not primarily medical in nature and not covered by Medicare.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. A walk-in
bathtub is not considered to be durable medical equipment per Medicare Guidelines. Also, Medicare does not
cover home modifications. Therefore, we decided that the Plan does not have to pre-approve a walk-in tub.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Skilled Nursing Facility (SNF) services provided October 1 to October 23, 2019.You asked the Plan to waive the copayment for the SNF services. You say that the copayment should be waived.The Plan denied your request. The Plan says the proper copayment was applied.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 $150 per day copayment for days 21-45 of a SNF stay. You have been asked to pay a $900 copayment for 6 days of SNF care (Days 21 through 26 of the admission). 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 Skilled Nursing Facility (SNF) services provided October 1 to October 23, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve root therapy (D3410 x 2), retrograde fillings (D3430 x 2), the initial 15 minutes of general anesthesia (D9222), and 3 additional 15minutes of general anesthesia (D9223).You asked the Plan to pre-approve the dental services. You say that you could die from the infection under your crown. You also say that you have a condition with your blood and you cannot risk anything going wrong with your health.The Plan denied your request. The Plan says root therapy, retrograde fillings and general anesthesia are not listed as covered 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 requested dental services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approve root therapy (D3410 x 2), retrograde fillings (D3430 x 2), the initial 15 minutes of general anesthesia (D9222), and 3 additional 15 minutes of general anesthesia (D9223).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services. You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says the requested treatment is available with an in-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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physician's services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on February 26, 2019.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 laboratory services provided on February 26, 2019.