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

We decided that the Plan does not have to pre-approve ankle foot orthoses and additions.

You asked the Plan to pre-approve Ankle foot orthosis, plastic with ankle joint, custom fabricated (L1970), Addition to lower extremity orthosis, soft interface for molded plastic, below knee section (L2820), Addition to lower extremity, varus/valgus correction, plastic modification, padded/lined (L2275), Addition to lower extremity, molded inner boot (L2280), Addition to lower extremity, dorsiflexion and plantar flexion assist/resist, each joint (L2220). You say that the enrollee needs the orthoses. The Plan denied your request. The Plan says the bilateral ankle foot orthoses are not medically 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 Ankle foot orthosis, plastic with ankle joint, custom fabricated (L1970), Addition to lower extremity orthosis, soft interface for molded plastic, below knee section (L2820), Addition to lower extremity, varus/valgus correction, plastic modification, padded/lined (L2275), Addition to lower extremity, molded inner boot (L2280), Addition to lower extremity, dorsiflexion and plantar flexion assist/resist, each joint (L2220). Our reviewer says that the orthoses are not medically necessary. Our physician reviewer found in this case the record indicates that the enrollee has bilateral foot drop with contractures. The provided record does not establish that the enrollee is ambulatory. The provided records do not indicate that the enrollee has the potential to benefit functionally from the requested services. The elements of the coverage rule are not satisfied. The requested services cannot be recommended. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Ankle foot orthosis, plastic with ankle joint, custom fabricated (L1970), Addition to lower extremity orthosis, soft interface for molded plastic, below knee section (L2820), Addition to lower extremity, varus/valgus correction, plastic modification, padded/lined (L2275), Addition to lower extremity, molded inner boot (L2280), Addition to lower extremity, dorsiflexion and plantar flexion assist/resist, each joint (L2220) have not been met. Therefore, we decided that the Plan does not have to pre-approve ankle foot orthoses and additions.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the requested SNF care is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for SNF care have not been met because the requested level of care is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee has no identifiable skilled nursing service needs. The enrollee does have identifiable skilled therapy service needs; however, the enrollee does not require skilled services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) the adjust complete denture - mandibular (D5411), and the panoramic radiographic image (D0330) received March 9 and March 17, 2021.
You asked the Plan to pay for the dental services. You say that you should not have to pay anything for these services. The Plan denied your request. The Plan says there is no coverage for the requested services under your supplemental benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the 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 limited oral evaluation - problem focused (D0140) the adjust complete denture - mandibular (D5411), and the panoramic radiographic image (D0330) received March 9 and March 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator.
You asked the Plan to pre-approve a home ventilator. You say that this ventilator is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the coverage criteria for this device have not been met as the ventilator is being used to provide continuous positive airway pressure.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 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 a home ventilator. Our reviewer says that the requested item is not medically reasonable and necessary. Our physician reviewer found that you have heart failure with reduced ejection fraction (HFrEF) which is quite severe, leading to repeated hospitalizations for acute on chronic respiratory failure. A diagnosis of COPD is also listed, although there are no pulmonary function tests for confirmation. You have been treated with bilevel positive airway pressure (BiPAP) in the hospital.
The ventilator is being ordered to be used as BiPAP, but Medicare does not cover a ventilator for this purpose. Certain BiPAP devices can provide the average volume-assured pressure support (AVAPS) mode that has been ordered. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to reimburse additionally for the COVID 19 testing provided on December 18, 2020.
You asked the Plan to reimburse additionally for the COVID 19 testing. You say that you feel you should be reimbursed additionally for the COVID testing you paid for out of pocket. The Plan denied your request. The Plan says that the amount reimbursed to you was correct.
The Plan must follow Medicare rules. Medicare rules say group health plans and issuers offering group or individual health insurance coverage must cover COVID-19 diagnostic tests without cost sharing, prior authorization, or other medical management requirements. It is the Plan's responsibility to ensure that enrollees are not charged for COVID 19 testing. Therefore, we decided that the Plan has to reimburse additionally for the COVID 19 testing provided on December 18, 2020.
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 additional routine transportation trips.
You asked the Plan to pre-approve the additional routine transportation trips. You say that you do not have any outside help with getting to your medical appointments. You say that you have reached out to all the different transportation possibilities, and none have been able to assist and you cannot afford other type services. You say that mobility buses do not service the locations of your providers. The Plan denied your request. The Plan says the benefit only allows 36 one-way transportation trips per calendar year.
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 up to 36 one-way trips per calendar year. We looked at your request, the records in the case file, and the rules. The file shows that the Plan covers up to 36 one-way transportation trips per year. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endodontic therapy, premolar tooth (excluding final
restoration) (D3320).

You asked the Plan to pre-approve the endodontic therapy. You say that you would like the service covered.
The Plan denied your request. The Plan says this service is not covered under your 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 pre-approve
endodontic therapy, premolar tooth (excluding final restoration) (D3320).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a recliner chair (E1399).

You asked the Plan to pre-approve the chair. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.

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 recliner chair (E1399).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a carotid Doppler.
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 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has hyperlipidemia and obesity. There are no symptoms of carotid artery disease. The physical examination did not show any bruits. There is no evidence of carotid occlusion. The records do not support that the criteria for coverage are met. The carotid Doppler is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a carotid Doppler.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the CT scan provided on May 29, 2019.
You asked the Plan to pay for the CT scan. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the claim was not filed timely per Medicare guidelines.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for the CT scan was not filed until April 2, 2021. 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 CT scan provided on May 29, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve laboratory tests (81240, 81241) for the enrollee.

You asked the Plan to pre-approve the tests. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that MTHFR testing is only covered for pregnant patients. 

You do not qualify for this testing. Based on this information, we decided that Medicare rules for coverage of the tests have not been met. Therefore, we decided that the Plan does not have to pre-approve laboratory tests (81240, 81241) for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of SNF care from July 27, 2021, forward.
You asked the Plan to pre-approve SNF care. You say that SNF care would be beneficial before returning home. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of SNF care from July 27, 2021, forward.
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 was independent prior to this admission. The Plan denied your request. The Plan says the enrollee does not require 3 hours of therapy a day.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

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 was admitted to the acute care hospital for bilateral lower extremity cellulitis and left foot osteomyelitis. His medical conditions are stable. There are no complex nursing needs. He does require physical and occupational therapy but there is no documented need for an intensive rehabilitation 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Dexcom G6 CGM System and other supplies (CPT code(s): K0554, K0553, and A6212) to be provided by an out-of-network provider.
You asked the Plan to pre-approve the items. You say that the enrollee will benefit from switching over to Dexcom CGM. The Plan denied your request. The Plan says the requested items are available from 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. Review of the information provided shows that the enrollee received a Freestyle Libre CGM on July 5, 2021, from their pharmacy. There is no indication the enrollee's current CGM is lost or irreparable. All supplies
needed for the use of the CGM is included under one billing code and are not able to be billed separately. In addition, the provider is not contracted to provide CGMs and supplies. There are in-network providers available to provide this service. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 CGM System and other supplies (CPT code(s): K0554, K0553, and A6212) to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve in-network coverage for the removal implant (RT) and 1-day inpatient stay (CPT code 20680) to be provided by an out-of-network provider.
You asked the Plan to pre-approve the services. You say that you are requesting in-network benefit coverage with an out-of-network provider. The Plan denied your request. The Plan says this service is available by a provider in your network. However, if you choose to receive services from this out of network provider, your share of the cost for your covered services may be higher.
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. Based on this information, this service is available by a provider in your network. However, if you choose to receive services from this out of network provider, your share of the cost for your covered services may be higher. Therefore, we decided that the Plan does not have to pre-approve in-network coverage for the removal implant (RT) and 1-day inpatient stay (CPT code 20680) to be provided by an out-of-network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation (A0427) received February 8, 2021.
You asked the Plan to waive the copayment for the ambulance transportation. You say that you wanted to be transported by a "Rescue Squad." The Plan denied your request. The Plan says you were transported by the ambulance company and the correct cost share applied to the claim.
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 $250 copayment for Ambulance Services. You have been asked to pay a $250 copayment for the ambulance transportation. The ambulance transportation 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 transportation (A0427) received February 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care. The enrollee does not require services at the LTACH that are not available at the present setting where he is currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the injection provided on January 27, 2021.
You asked the Plan to waive the coinsurance for the injection. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received an injection on the date of service at issue in this appeal. The Plan says that the correct coinsurance has applied per your contract 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 20% coinsurance for Medicare Part B prescription drugs. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received an injection on January 27, 2021. You have been asked to pay a 20% coinsurance for the injection, totaling $165.31. The injection falls within the Medicare Part B prescription drugs benefit category.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the injection provided on January 27, 2021.