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

We decided that the Plan has to pre-approve a special power wheelchair (made for persons with nerve or
muscle diseases).
You asked the Plan to pre-approve a special power wheelchair (made for persons with nerve or muscle
diseases). You say that the requested item is necessary. The Plan denied your request. The Plan says that based
on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that a PMD will be covered if the patient has a mobility
deficit that impairs their participation in MRADLs, the patient's condition cannot be ameliorated by a walker,
cane or manual wheelchair, and the patient is 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 a special power wheelchair (made for
persons with nerve or muscle diseases). Our reviewer says that the item is medically necessary. Our physician
reviewer found you require maximum assistance for performing a stand pivot transfer and are nonambulatory.
You are described as unable to propel a manual wheelchair. Despite use of a jazzy you have fallen multiple
times in the past week. Standard mobility aids including a scooter would not meet your wheelchair and seating
needs. There is no identified condition that would be expected to limit your ability to safely operate a PMD.
You currently use a Jazzy and have also used a power wheelchair.
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 special power wheelchair (made for persons with nerve or muscle diseases)
have been met. Therefore, we decided that the Plan has to pre-approve a special power wheelchair (made for
persons with nerve or muscle diseases).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a resin-based composite - four or more surfaces or involving incisal angle (anterior) for tooth #28.
You asked the Plan to pre-approve the resin-based composite - four or more surfaces or involving incisal angle (anterior) for tooth #28. The Plan denied your request. The Plan says this service is not a covered benefit for tooth #28. The Plan also says that the provider may choose to resubmit a corrected prior authorization request.
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, resin-based composite - four or more surfaces or involving incisal angle (anterior) for tooth #28 is not covered under this benefit because tooth #28 is a posterior tooth. Therefore, we decided that the Plan does not have to pre-approve a resin-based composite - four or more surfaces or involving incisal angle (anterior) for tooth #28.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 5, 2019 by an out of network (OON) provider.
You asked the Plan to pay for office services. You say that you thought you were participating with all plans and did not know that you were not participating with this particular plan. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and the enrollee self-directed for service.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on October 5, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Neoral for the enrollee. 
 
You asked the Plan to pre-approve Neoral. You say that the enrollee has exhausted other treatment options. The Plan denied your request. The Plan says Neoral to be taken at home is not covered under the Part B benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered 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 Neoral for the enrollee.  
 
Benefits for Neoral 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Linzess Cap 72MCG.
You asked the Plan to pre-approve Linzess Cap 72MCG. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.
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 Linzess Cap 72MCG.
Benefits for Linzess Cap 72MCG 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 to pay for a lumbar-sacral orthosis (L0650) and a shoulder orthosis (L3960) provided to the enrollee on October 10, 2019.
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your request. The Plan says the enrollee has previously received the same supplies within the 5-year RUL.
The plan must follow Medicare rules. Medicare rules say that the reasonable useful lifetime of durable medical equipment is no less than five years. Replacement equipment may be granted when irreparable wear or irreparable damage is demonstrated or there has been a change in the enrollee's medical condition. We looked at the file and Medicare rules. In this instance, the submitted documentation indicates that the enrollee has received the same durable medical equipment on October 19, 2018. These orthoses are still within
the 5-year RUL and the documentation submitted does not show that the orthoses are irreparably worn, irreparably damaged, or that the enrollee had a change in medical condition to warrant the orthoses at issue. Based on this information, we decided that Medicare rules for coverage of the orthoses have not been met. Therefore, we decided that the Plan does not have to pay for to pay for a lumbar-sacral orthosis (L0650) and a shoulder orthosis (L3960) provided to the enrollee on October 10, 2019.
Appeal type: Lab
Decision: Favorable

The rules say that the date of service for lab testing generally should be the date that the specimen was collected. However, in the case of a chemotherapy sensitivity test/service performed on live tissue, the DOS of the test/service must be the date the test/service was performed only if: 
 
-The decision regarding the specific chemotherapeutic agents to test is made at least 14 days after discharge; -The specimen was collected while the patient was undergoing a hospital surgical procedure; -It would be medically inappropriate to have collected the sample other than during the hospital procedure for which the patient was admitted; -The results of the test/service do not guide treatment provided during the hospital stay; and -The test/service was reasonable and medically necessary for treatment of an illness. 
 
You can find this information in the Medicare Claims Processing Manual, Chapter 16, Section 40.8. 
 
The rules say that a contract plan provider is an agent of the plan. Services and referrals obtained from a plan provider are viewed as plan-approved unless notice is given that the services will not be covered. When a plan provider gives, or refers an enrollee for, a service that the enrollee reasonably believes is covered by the plan, the enrollee is held harmless and need not pay more than the plan-allowed cost-sharing for that service.  
 
If a service is never covered by the plan and the plan's Evidence of Coverage (EOC) is clear that the service or item is never covered, the plan does not have to hold the enrollee harmless.  
 
For a service or item that is normally not covered, but could be covered under some conditions, the EOC alone is not adequate notice of non-coverage. If no notice of non-coverage is given, the enrollee is held harmless. You can find this rule in the Medicare Managed Care Manual, Chapter 4, Section 160.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on August 13, 2019. 
 
You asked the Plan to pay for the psychotherapy services. You say that you did not know that you needed prior authorization as you had been receiving therapy services before. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization. 
 
The Plan must follow Medicare rules. Medicare rules say that a social worker is not eligible to participate in the Medicare program. 
 
We looked at the file and Medicare rules. The file shows that the psychotherapy services were provided. A social worker is not eligible to participate in the Medicare program. Therefore, we decided that the Plan does not have to pay for psychotherapy services provided on August 13, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the surgical placement of a mini implant (D6013 x 4),
and a modification for a removable prosthesis following implant surgery (D5875).
You asked the Plan to pre-approve the mini implants and the denture adjustment. You say that the dental
services are required for your health concerns. You say that you have received dental work from another
provider that has ruined your jaw and gums. You say that you need these services to fix the issues you have.
The Plan denied your request. The Plan says the placement of a mini implants and denture adjustments are not
listed as covered services.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested dental services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the
surgical placement of a mini implant (D6013 x 4), and a modification for a removable prosthesis following
implant surgery (D5875).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the supply allowance for the continuous glucose
monitor.
You asked the Plan to pre-approve the supply allowance. You say that you need the supply allowance. The
Plan denied your request. The Plan says there is no record of frequent adjustment of your insulin regimen and
you have not had an in-person visit with your treating practitioner every six months.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they
are medically reasonable and necessary and replace a blood glucose monitor.
We looked at the file and Medicare rules. There is no record of physician visits every six months or frequent
adjustments of your insulin treatment. Based on this information, we decided that Medicare rules for coverage
of the supply allowance have not been met. Therefore, we decided that the Plan does not have to pre-approve
the supply allowance for the continuous glucose monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the physician services to be provided by an out of network (OON) provider. 
 
You asked the Plan to pre-approve the physician services. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are neither emergent nor urgent to seek out-of-network care. The Plan states there are in-network thoracic surgeons available to you.
 
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 physician services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that plans may choose the networks of providers available to enrollees and may require enrollees to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in the Medicare Managed Care Manual, Chapter 1, Section 20.2.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that, with limited exceptions, members of the Plan must use network providers to get medical care and services. The only exceptions are emergencies, urgently needed care when the network is not available (generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan authorizes the use of out-of-network providers. You can find this information on page 3-4 of the plan's 2019 Evidence of Coverage.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the Acetaminophen-codeine, Insulin Aspart, Amitriptyline, Gabapentin, Famotidine, Loratadine, and Rosuvastatin provided from June 17, 2019 to June 20, 2019.
You asked the Plan to pay for these drugs. You say that the plan did not indicate which items were denied as well as the reason for the denials. The Plan denied your request. The Plan says Self-administered drugs provided in a hospital outpatient setting are not covered by the plan or Medicare.
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 provided here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the Acetaminophen-codeine, Insulin Aspart, Amitriptyline, Gabapentin, Famotidine, Loratadine, and Rosuvastatin provided from June 17, 2019 to June 20, 2019.
Benefits for these drugs 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network orthopedic surgeon.
You asked the Plan to pre-approve these services. You say that you do not like the doctor to which you were
referred. The Plan denied your request. The Plan says the services are available from network providers.
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. The Plan confirmed they have two
orthopedic surgeons other than the original doctor you were referred to from which you may receive services.
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 a referral to an out-of-network orthopedic surgeon.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on
October 8, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your
request. The Plan says the enrollee has previously received the same supplies within the 5-year RUL.
The plan must follow Medicare rules. Medicare rules say that the reasonable useful lifetime of durable
medical equipment is no less than five years. Replacement equipment may be granted when irreparable wear or
irreparable damage is demonstrated or there has been a change in the enrollee's medical condition.
We looked at the file and Medicare rules. In this instance, the submitted documentation indicates that the
enrollee has received the same durable medical equipment on March 22, 2018. This orthosis is still within the
5-year RUL and the documentation submitted does not show that the orthosis is irreparably worn, irreparably
damaged, or that the enrollee had a change in medical condition to warrant the orthosis at issue. 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 pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on
October 8, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Entresto medication.
You asked the Plan to pre-approve this medication. You say that this medication is medically necessary to treat the patient's condition. The Plan denied your request. The Plan says the enrollee has a medical (MA) only policy with the Plan, not a Prescription Drug Plan (PDP). Therefore, drug coverage is limited to Medicare Part B covered drugs only.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve the Entresto medication.
Benefits for this medication 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 pre-approve compression stockings identified with code A6533, A6534.
You asked the Plan to pre-approve the compression stockings. You say that you need the compression stockings for your lymphedema. The Plan denied your request. The Plan says this is a non-covered item.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533, A6534 are non-covered 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 A6533, A6534.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for eyeglasses provided, on August 27, 2019.
You asked the Plan to reimburse you for the eyeglasses. The Plan denied your request. The Plan says you must use the plan for your eyewear benefit.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file and the Plan's rules. The requested provider in this case is not a network vision care provider with the Plan. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to reimburse you for eyeglasses provided on August 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for podiatry services provided on October 1, 2019.
You asked the Plan to waive the copayment for podiatry services. You say that you were told that the provider was in-network. 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 copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 copayment for podiatry services. You have been asked to pay a $35 copayment for podiatry services. Podiatry services fall within the podiatry 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 podiatry services provided on October 1, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from April 4, 2019 to April 8, 2019.
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you should not have a copayment because your primary coverage is with Medicare and your secondary coverage is with the plan. 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $295 copayment for each day for days 1 to 6 for Medicare-covered hospital care. You have been asked to pay a $295 copayment for each day of the inpatient hospital stay. ($295 x3 days = $885). The inpatient hospital stay 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 inpatient hospital stay provided from April 4, 2019 to April 8, 2019.