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

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
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 enrollee does not meet the criteria for coverage.
The Plan must follow Medicare rules. Medicare rules say that a therapeutic CGM is covered when specific criteria are met. We looked at the file and Medicare rules. The file shows that the enrollee does not have a diagnosis of diabetes and is not insulin-treated. 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 continuous glucose monitor (CGM).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the carotid artery stent procedure provided
from September 23, 2020, to September 25, 2020.
You asked the Plan to waive the copayment for the carotid artery stent procedure. You say that you were told
you would only be in the hospital for one day and owe a $393 copayment. The Plan denied your request. The
Plan says you have been asked to pay the correct cost-sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $393
copayment for each day for days 1-5.
You have been asked to pay a $393 copayment for each day of the carotid artery stent procedure. ($393 x 2
days = $786). The carotid artery stent procedure falls within the "Inpatient hospital care" 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 carotid artery stent procedure provided from September
23, 2020, to September 25, 2020.
Your complaint about the hospital's delay is not a valid appeal for medical coverage. This part of your
complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision
about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.

You asked the Plan to pre-approve the requested monitor. You say that the enrollee has compliance issues. The Plan denied your request. The Plan says the enrollee does not meet qualifications.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. 

We looked at the file and Medicare rules. The documentation does not indicate that the enrollee performs blood glucose testing at least four times per day, uses insulin with at least three daily injections, and requires frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the requested monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to approve 10 additional physical therapy (PT) sessions.
You asked the Plan to 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. The rules say that Medicare pays for medically necessary outpatient therapy. 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 approve these services. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the records show that you are able to walk 95 feet with supervision and a wheeled walker. You need some supervision with transfers and bed mobility. The records do not show that the additional therapy would be specific and effective for your condition. You have had prior therapy and the records do not show that your functional level requires the ongoing unique skills of a professional therapist to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. The services are not part of a maintenance program and are not needed to establish, design, and/or deliver a program to maintain your condition or prevent further deterioration. 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 approve 10 additional physical therapy (PT) sessions.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the enteral feeding supply kit (B4035) and enteral formula
(B4153) provided on June 17, 2020, through July 16, 2020.

You asked the Plan to pay for the enteral feeding supply kit and formula. You say that you would like
reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation
submitted does not include an itemized billing/shipping invoice to verify the billed supplies.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a
physician order and proof of delivery.

The record does not contain a valid proof of delivery for the supplies provided in this case. The record shows
that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we
decided that the Plan does not have to pay for the enteral feeding supply kit (B4035) and enteral formula
(B4153) provided on June 17, 2020, through July 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you $3,000 for hearing aids provided on August 13, 2020.

You asked the Plan to reimburse you $3,000 for the hearing aids. The Plan denied your request. The Plan says that the Plan paid the maximum benefit amount.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids with an allowance of $500 for up to 2 hearing aids per year (both ears combined). 

We looked at the file and the Plan's rules. The file shows that the Plan paid the maximum benefit amount for the hearing aids. Therefore, we decided that the Plan does not have to reimburse you $3,000 for hearing aids provided on August 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network provider on February 27, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 services at issue in this appeal. 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 the services provided to the enrollee by an out-of-network provider on February 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on September 6, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the office visit. You say that you are requesting retro-authorization for the out of network office visit. The Plan denied your request. The Plan says no prior authorization was 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 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 office visit provided on September 6, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) provided on November 25, 2020.
You asked the Plan to pay for the comprehensive periodontal evaluation. You say that you believe this service should be covered. The Plan denied your request. The Plan says this service is not a covered benefit under your dental 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 pay for the comprehensive periodontal evaluation (D0180) provided on November 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the consultation to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the consultation. You say that this provider is highly recommended, and you would like to see him. The Plan denied your request. The Plan says a preauthorization is required to obtain services from a non-contract 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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the consultation to be provided by an out of network (OON) provider.
Your complaint about the Plan's irresponsiblity is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a manual wheelchair with protection and positioning cushions and a manual swingaway.

You asked the Plan to pre-approve manual wheelchair with accessories.. You say that this wheelchair will help with the enrollee's pain, and the requested cushions will significantly minimize the risk of the enrollee's sustaining skin injuries in the future. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for the requested wheelchair and accessories.

The Plan follows Medicare rules. Medicare rules state that manual wheelchairs may be met if certain specific criteria are met.

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 manual wheelchair with accessories. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested manual wheelchair with accessories. Our physician reviewer found the documentation does indicate that the enrollee has a mobility limitation, but the documentation indicates that the enrollee lives in a long-term care facility with assistance with grooming, bathing, dressing from staff. It is not clear that the enrollee's mobility limitation cannot be sufficiently overcome with her current manual wheelchair per the consulting evaluation. The documentation does not reveal that the requested wheelchair will significantly improve the enrollee's mobility-related activities of daily living. As the requested wheelchair (E1161) is not medically necessary, the requested seating and accessory components are also 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 manual wheelchair with accessories. have not been met. Therefore, we decided that the Plan does not have to pre-approve a manual wheelchair with protection and positioning cushions and a manual swingaway.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6534.

You asked the Plan to pre-approve the compression stockings. You say that the compression stockings are
medically necessary. The Plan denied your request. The Plan says the stockings are not covered.

The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6534
are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that
compression bandages and gradient compression wraps are covered only when they are used as dressings over
a qualifying wound.

The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you
do not have a medical condition for which compression stockings can be covered or paid for by Medicare.
Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code
A6534.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mastectomy sleeve.

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 covered.

The Plan must follow Medicare rules. The rules say that a mastectomy sleeve (L8010) is denied as non-covered.

We looked at the file and Medicare rules. The item at issue is a mastectomy sleeve. This item is denied by Medicare as non-covered. Therefore, we decided that the Plan does not have to pre-approve a mastectomy sleeve.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the hip x-ray provided on December 2, 2020.
You asked the Plan to waive the copayment for the hip x-ray. You say that you were never given a diagnosis or showed the x-rays. You say that you should not have been charged. The Plan denied your request. The Plan says the copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $95 copayment for basic radiological services at an in-network outpatient hospital. You have been asked to pay a $95 copayment for the hip x-ray. The hip x-ray falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the hip x-ray provided on December 2, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care (99233) provided on December 6, 2020.
You asked the Plan to pay for the subsequent hospital care. You say that you would like reconsideration because the member was not enrolled in hospice on the billed date of service. The Plan denied your request. The Plan says the provider needs to bill Original Medicare, using the proper modifiers, for services rendered on December 06, 2020.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on December 5, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care (99233) provided on December 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve adjustable elbow extension/flexion device.

You asked the Plan to pre-approve adjustable elbow extension/flexion device. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested item is 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 adjustable elbow extension/flexion device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the literature does not reveal that mechanical stretching devices are effective for chronic muscle contractures and the literature does not reveal sufficient evidence of long term effectiveness for the use of this device in your condition of hemiparesis with contracture and spasticity. Therefore, you do not meet criteria for the requested item. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of adjustable elbow extension/flexion device have not been met. Therefore, we decided that the Plan does not have to pre-approve adjustable elbow extension/flexion device.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MRI (magnetic resonance imaging) of the shoulder.

You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your
request. The Plan says a trial of conservative measures is incomplete at this point.

The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 the MRI. Our reviewer says that the
requested MRI is not medically reasonable or necessary. Our physician reviewer found detailed documentation
is not evident regarding trial and failure of recent, reasonable and comprehensive less invasive conservative
care measures. There is no compelling rationale presented or extenuating circumstances noted to support the
medical necessity of this request as an exception to guidelines. Therefore, the request for MRI of the shoulder
is not medically reasonable or 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 the MRI have not been met. Therefore, we decided that the Plan does not have
to pre-approve MRI (magnetic resonance imaging) of the shoulder.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sideguards for a power wheelchair (K0108) for the
enrollee.
You asked the Plan to pre-approve the sideguards. 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 sideguards for a power wheelchair (K0108) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies (A4927, T4541, A6250).

You asked the Plan to pre-approve the incontinence supplies. You say that these items are medically necessary. The Plan denied your request. The Plan says the requested pads, gloves, and moisturizer are not covered items.

The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. 

While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies (A4927, T4541, A6250).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.
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 lumbar spinal stenosis with neurogenic claudication. Current evidence and medical guidelines do not support the use of the Superion spacer over the gold standard of a lumbar laminectomy. The services are considered experimental in nature and 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.