Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payments for debridement provided on January 5, 2021, and January 12, 2021.

You asked the Plan to waive the co-payments for debridement. You say that you disagree with the charges because the building was not connected to a hospital and was a regular office. 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 co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $295 co-payment for outpatient surgery, including services provided at hospital outpatient facilities.

The record shows that you received debridement on January 5, 2021, at an outpatient hospital facility. Therefore, you are responsible to pay the $295 co-payment.

The record shows that you received debridement on January 12, 2021, at an outpatient hospital facility. Therefore, you are responsible to pay the $295 co-payment.

The total amount you owe is: $590.

You have been asked to pay the total co-payment amount of $590 for debridement. Debridement falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 co payments for debridement provided on January 5, 2021, and January 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from December 9, 2020, through December 16, 2020.

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the services provided.

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 $310 copayment per day, per admission, for days 1-7 for in-network inpatient hospital care. Additionally, you pay $0 per day, per admission for days 8-90. 

You have been asked to pay $917.65 ($310 copayment x 7 days) for the inpatient hospital care provided. This is the Plan allowed amount which is less than the applicable copayment for this service. 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 inpatient hospital care provided from December 9, 2020, through December 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the durable medical equipment provided by an ineligible provider on July 27, 2020.

You asked the Plan to pay for the durable medical equipment. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the provider is not eligible to bill Medicare.

The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. 

Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the durable medical equipment provided by an ineligible provider on July 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a grab bar.

You asked the Plan to pre-approve a grab bar. You say that this is to keep you from getting injured in the shower. 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 grab bars are not covered because they are not primarily medical in nature. 

While a grab bar 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 grab bar.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a gum surgery (D4266), prefabricated abutment (D6056), implant supported porcelain fused metal crown (D6066), implant removal (D6100), and bone replacement graft for ridge preservation (D7953).

You asked the Plan to pre-approve the gum surgery, prefabricated abutment, implant supported crown, implant removal, and bone replacement graft. You say that you would like these services to be approved for coverage. The Plan denied your request. The Plan says these services are not covered under your benefit plan.

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 a gum surgery (D4266), prefabricated abutment (D6056), implant supported porcelain fused metal crown (D6066), implant removal (D6100), and bone replacement graft for ridge preservation (D7953).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Nepro Carb Ready enteral formula.

You asked the Plan to pre-approve this item. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says you do not meet criteria for coverage of enteral formula.

The Plan follows Medicare rules. Medicare rules say that enteral nutrition is considered reasonable and necessary for a patient with a functioning gastrointestinal tract who, due to pathology to, or non-function of, the structures that normally permit food to reach the digestive tract, cannot maintain weight and strength commensurate with his or her general condition. 

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 this item. Our reviewer says that this request for enteral nutrition is not medically necessary. Our physician reviewer found that based on the medical records reviewed, there is no specific diagnosis documented to support your inability to eat foods orally. For this reason, you do not have a medically necessary diagnosis for enteral feeds. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this item have not been met. Therefore, we decided that the Plan does not have to pre-approve Nepro Carb Ready enteral formula.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a recumbent bicycle and work bench.

You asked the Plan to pre-approve these services. You say that the services should be covered. The Plan denied your request. The Plan says the items 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 recumbent bicycle and work bench.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aid repair and battery provided on
September 16, 2020.

You asked the Plan to pay for the hearing aid repair and battery. The Plan denied your request. The Plan says hospice services are to be billed directly to Federal Medicare.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for hearing aid repair and battery provided on
September 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core build up (D2950) for teeth # 8 and 9.

You asked the Plan to pre-approve the core build up. You say that both teeth 8 and 9 have had composites that are failing. You say that they show structural loss from day under and around the old composites. The Plan denied your request. The Plan says that core build up are not listed as covered services either.

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 core build up are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core build up (D2950) for teeth # 8 and 9.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says appropriate intensive rehab services at the IRF can continue to be received.

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 the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF. The documentation does not reveal evidence of complex wound care, new enteral feedings, or other skilled nursing SNF need. Your functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment. You do not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter, you do not require the necessary services on an inpatient basis, in a skilled nursing facility setting. Your needs are currently being met in the IRF, and can continue until there is a discharge plan to home or a community 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 the admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar orthosis (L0627).

You asked the Plan to pre-approve the orthosis. You say that the orthosis is medically necessary. The Plan denied your request. The Plan says the documentation does not support the item requested.

The Plan must follow Medicare rules. Medicare rules say that documentation must be sufficiently detailed to include, but is not limited to, a detailed description of the modifications necessary at the time of fitting the orthosis to the beneficiary. 

We looked at the file and Medicare rules. The records provided were limited. There was no documentation as to why a custom fitted device is required for this enrollee. Based on this information, we decided that Medicare rules for coverage of the orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve a lumbar orthosis (L0627).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6549.

You asked the Plan to pre-approve the compression stockings. You say that the requested compression stockings are 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 compression stockings described by code A6549 are noncovered because they do not meet the statutory definition of a surgical dressing. 

Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed for the enrollee.

You asked the Plan to pre-approve the bed. You say that this is medically necessary. The Plan denied your request. The Plan says the height adjustment feature of this bed is a convenience feature.

The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.

While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power mobility device (K0813).

You asked the Plan to pre-approve power mobility device. You say that the power mobility device is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

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. 

The records do not include any home evaluation showing that the enrollee can safely operate the power mobility device in the home. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a power mobility device (K0813).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a grab bar.
You asked the Plan to pre-approve a grab bar. You say that this is for safety in the shower to prevent falls. 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 grab bars are not covered because they are not primarily medical in nature. While a grab bar 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 grab bar.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a psychotherapy visit provided on June 11, 2020 by an out of network (OON) provider.

You asked the Plan to pay for practitioner visit. You say that your provider depends upon the facility staff to verify eligibility and obtain proper authorization. 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 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 had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for a psychotherapy visit provided on June 11, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the x-rays provided from August 7, 2020 to August 12, 2020.

You asked the Plan to waive the copayments for the x-rays. 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 x-ray on each date of service at issue in this appeal. The Plan says that the correct copayments have 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 $35 copayment for each outpatient x-ray, diagnostic procedure and test.

We looked at the file, the Plan's contract and Medicare rules. The file shows that you had an x-ray on August 7, 2020, August 10, 2020, and August 12, 2020. You have been asked to pay a $27.24 copayment for each x-ray, which is less than the contracted $35 copayment amount for the x-rays. The x-rays fall within the Outpatient diagnostic tests benefit category. This means that you have been asked to pay the correct amounts 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 copayments for the x-rays provided from August 7, 2020 to August 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on December 1, 2020 by an out of network (OON) provider.

You asked the Plan to pay for office visit. You say that due to the short time period you were unable to get authorization before the service was performed. 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 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 had network providers available who could have provided 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 an office visit provided on December 1, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a sensor (A9276) for use with a continuous glucose monitor.

You asked the Plan to pay for the sensor. You say that this is medically necessary. The Plan denied your request. The Plan says this is considered precautionary and therefore non-covered.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. The rules say that HCPCS A9276 is not a covered code. 

The requested sensor is coded in such a way that makes it statutorily not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of the sensor have not been met. Therefore, we decided that the Plan does not have to pay for a sensor (A9276) for use with a continuous glucose monitor.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve massage therapy.

You asked the Plan to pre-approve the massage therapy. You say that member has been going to massage therapy for his diagnosis of fibromyalgia and cervical radiculopathy and the sessions have significantly improved the members quality of life. You say that he is able to take less pain medication since he is having pain relief with massage therapy. The Plan denied your request. The Plan says Medicare does not cover the services of a massage therapist. There is no indication that massage therapy is being performed as an adjunct to another medically necessary treatment.

The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, we decided that the Plan does not have to pre-approve massage therapy.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Levothyroxine.

You asked the Plan to pre-approve Levothyroxine. You say that this request is medically necessary. The Plan denied your request. The Plan says drug coverage is limited to those drugs covered under the medical benefit.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Levothyroxine.

Benefits for Levothyroxine may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for blood glucose test strips.

You asked the Plan to pay for test strips. You say that the test strips will allow manual readings to calibrate your sensors. The Plan denied your request. The Plan says the supplies are not covered.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. We looked at the file and the rules. 

We find that CPT code A4253 (test strips) is not supported. The file shows that you were approved for a continuous glucose monitor. Test strips are not covered in addition to a continuous glucose monitor. Based on this information, we decided that Medicare rules for coverage of test strips have not been met. Therefore, we decided that the Plan does not have to pay for blood glucose test strips.