Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the initial periapical x-ray (D0220) provided on September 19, 2019.
You asked the Plan to reimburse you for the dental service. You say that the 2020 Evidence of Coverage specifically states that periapical x-rays are a covered service. You also say that you should be reimbursed the 50% coinsurance. The Plan denied your request. The Plan says the periapical x-ray is not listed as a covered service for 2019.
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 periapical x-ray is not among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for the initial periapical x-ray (D0220) provided on September 19, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forinpatient mental health care provided to the enrollee from December 15, 2019 through December 24, 2019.You asked the Plan to pay forinpatient mental health care. You say that the claim should be paid.The Plan denied your request. The Plan says per records the member did not have any Lifetime Reserve days remaining.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient mental health care have not been met. The member did not have any lifetime reserve days remaining. The member did not have a 60-day break in stay;therefore,a new benefit period has not started. The facility has been confirmed as free standing via search engine. Per guidelines, if the lifetime reserve period is at zero but there are lifetime psychiatric days remaining there would be benefit exhaust at a free standing facility. On November 8, 2019 the member had 0 days available lifetime benefit.Therefore, we decided that the Plan does not have to pay forinpatient mental health care provided to the enrollee from December 15, 2019 through December 24, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that 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 was medically stable with no evidence ofneed for supervision by a physical medicine and rehabilitation (PMR) Physician or needs acute rehab nursing care. The enrollee may benefit from further physical therapy (PT) and occupational therapy (OT) but does not require an intensive therapy program. IRF admission is not medically necessary based on the enrollee's current functional status and medical stability.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage ofIRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device.You asked the Plan to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services are not medically necessary.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 insertion of interlaminar/interspinous process stabilization/distraction device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has chronic intractable pain. The requested device remains experimental. More research is needed to show safety and efficacy. Therefore, the enrollee does not meet criteria for the requested services.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of insertion of interlaminar/interspinous process stabilization/distraction device have not been met.Therefore, we decided that the Plan does not have to pre-approveinsertion of interlaminar/interspinous process stabilization/distraction device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit for the evaluation and management of an established patient (99335) rendered by the out of network (OON) provider on December 30, 2019.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was provided by an out of network provider, without 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 provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the domiciliary or rest home visit for the evaluation and management of an established patient (99335) rendered by the out of network (OON) provider on December 30, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvedental anesthesia.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services 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, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvedental anesthesia.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the mandibular partial denture.You asked the Plan to pre-approve the mandibular partial denture. The Plan denied your request. The Plan says this service does not meet the time limitation.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, complete or partial dentures are limited to 1 every 5 years. The record shows that the enrollee received a partial denture in 2017 and the enrollee's partial denture benefit has been exhausted.Therefore, we decided that the Plan does not have to pre-approve the mandibular partial denture.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the admission to a SNF.
You asked the Plan to pre-approve the SNF admission. You say that the enrollee is not receiving the care she needs in Home Health and requires therapy and medical services daily. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for admission to the SNF.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF admission. Our reviewer says that the enrollee does not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting.
We looked at this physician's review, the file, and Medicare rules. Although the enrollee has skilled therapy needs, these needs are not on a daily basis. Based on this information, we decided that Medicare rules for coverage of the SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve the admission to a SNF.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. The Plan denied your request. The Plan says that this is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two crowns and two core buildups, including any pins when required provided on June 3, 2019.
You asked the Plan to pay for the crowns and core buildups. You say that you have already paid for these services and would like to be reimbursed. The Plan denied your request. The Plan says these services are not covered 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 for the two crowns and two core buildups, including any pins when required provided on June 3, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea raised toilet seat.You asked the Plan to pre-approvea raised toilet seat. You say that you were recently discharged from a skilled nursing facility. You live alone and needs assistance with showering and using the restroom.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered because they are not primarily medical in nature. While a raised toilet seat may be appropriate, neither the Plan nor Medicare offers coverage of this item.Therefore, we decided that the Plan does not have to pre-approvea raised toilet seat.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve group 3 power wheelchair (K0861) with special power
options.
You asked the Plan to pre-approve group 3 power wheelchair with special power options. You say that please
reconsider the denial for the power wheelchair. The enrollee is an active power wheelchair user and requires
the requested item for all of her MRADL's inside and outside of the home. The Plan denied your request. The
Plan says the Medicare criteria has not been met for the special power 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.
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 group 3 power wheelchair with special
power options. Our reviewer says that the requested items/services are not considered medically reasonable and
necessary in this case. Our physician reviewer found the enrollee with a diagnosis of post-polio syndrome that
is causing difficulty with mobility related activities of daily living (MRADL's). She complains of ankle
cramping and pain, and poor ambulatory tolerance. She uses a power wheelchair for long distance ambulation.
In this case, the enrollee is not noted to have inability to utilize a lesser device (lightweight manual wheelchair,
standard manual wheelchair, or use of a walker). Therefore, this request is not medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of group 3 power wheelchair with special power options have not been met.
Therefore, we decided that the Plan does not have to pre-approve group 3 power wheelchair (K0861) with
special power options.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the physical therapy visits provided from
January 15, 2020 to January 30, 2020.
You asked the Plan to waive the deductible for the physical therapy visits. You say that you were told the
physical therapy visits would be fully paid. 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. Your
contract with the Plan says that there is a $750 deductible that applies towards physical therapy visits.
The physical therapy visits you asked the Plan to waive the deductible for falls within the "Outpatient
rehabilitation services" benefit category. The Plan has followed Medicare rules by clearly disclosing in the
contract that there is a $750 deductible that applies towards physical therapy visits. This cost sharing is a
contractual obligation that had not been met at the time the physical therapy visits were received from January
15, 2020 to January 30, 2020. Therefore, we decided that the Plan does not have to waive the deductible for the
physical therapy visits provided from January 15, 2020 to January 30, 2020.
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. You say that the enrollee requires continued daily medical
management, and physical and occupational therapy. The Plan denied your request. The Plan says the enrollee's
chronic conditions area stable, and he does not require an interdisciplinary approach to oversee rehab 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 is generally medically stable with stage IV cancer and debility with no recent neurological or
orthopedic events. 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. While the enrollee may benefit
from continuing physical and occupational therapy, there is no evidence of need for an intensive therapy
program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to
rehabilitation care.
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 pay for the comprehensive oral evaluation provided on February 13, 2020.
You asked the Plan to pay for the comprehensive oral evaluation. You say that you expected this service to be covered because you changed dentists. The Plan denied your request. The Plan says your benefit maximum for this service has been met.
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, comprehensive oral exams are limited to one every 36 months. The record shows that you received a comprehensive oral exam on February 27, 2019 and your comprehensive oral exams benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation provided on February 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a standing frame.
You asked the Plan to pre-approve the frame. You say that this is medically necessary. The Plan denied your request. The Plan says comfort, convenience, or luxury equipment or features are not covered
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 standing frame.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve176 additional routine transportation trips (A0100).You askedthe Plan to pre-approve176 additional routine transportation trips. You say that the requested additional transportation is necessary.The Plan denied your request. The Plan says the requested additional transportation trips exceed the benefit limit. Therefore, coverage criteria has not been met.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 a maximum of 36 one-way transportation trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation.Therefore, we decided that the Plan does not have to pre-approve176 additional routine transportation trips (A0100).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the portable oxygen concentrator provided on August 23, 2019.
You asked the Plan to waive the deductible for the portable oxygen concentrator. You say that you were informed this was covered with 15% or 20% coinsurance. You say that you cannot afford this. The Plan denied your request. The Plan says the deductible applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that your deductible is $975. This is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. Until you have paid the deductible amount, you must pay the full cost of your covered services. Out-of-network services are not excluded from the deductible. The item or service you asked the Plan to waive the deductible for falls within the "Durable medical equipment (DME) and related supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $975 deductible applies to out-of-network durable medical equipment. This cost sharing is a contractual obligation that had not been met at the time the portable oxygen concentrator was received on August 23, 2019. Therefore, we decided that the Plan does not have to waive the deductible for the portable oxygen concentrator provided on August 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvevenous ablation treatment.You asked the Plan to pre-approvethe requested services. You say that conservative management of edema and resultant pain has failed.The Plan denied your request.The Plan says there is no documentation of 3 months of conservative therapy.The Plan follows Medicare rules. Medicare rules say that treatment of varicose veins of the lower extremities is only covered under certain medical indications. We asked ourphysician 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 services. Our physician reviewer found that coverage requires the symptoms be attributable to the veins planed for treatment. It is not possible to attribute your activity-related leg pain to your varicose veins without an assessment of lower extremity arterial perfusion. There is no assessment of lower extremity arterial perfusion documented in the materials provided. If you indeed have significant peripheral arterial disease, vein ablation might be contraindicated. Additionally, there does not appear to be a concerted effort at conservative treatment documented. It is not clear if you were fitted for and reliably used medical grade compression stockings. Therefore, the documentation does not support the medical necessity of the requested services.