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

We decided that the Plan does not have to reimburse you for the wheelchair ramp provided on November 20, 2019.You asked the Plan to reimburse you for the wheelchair ramp. You say that you require a wheelchair ramp.The Plan denied your request. The Plan says wheelchair ramps are not covered by Medicare or the Plan.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. Medicare does not cover home modifications. Also, the item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home.Therefore, we decided that the Plan does not have to reimburse you for the wheelchair ramp provided on November 20, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the post stabilization inpatient care provided to the enrollee from September 21, 2019 to September 24, 2019.
You asked the Plan to pay for the post stabilization inpatient care. The Plan denied your request. The Plan says that the enrollee was stabilized prior to admission.
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required.
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 pay for the post stabilization inpatient care. Our reviewer says that inpatient care was not medically reasonable and necessary for the enrollee in this case. During the acute hospital stay from September 21, 2019 to September 24, 2019, there was no clear documentation of any instability sufficient to delay transfer. The enrollee did not appear ill and was comfortable with mild tenderness in the epigastric area and stable vitals. The enrollee began to tolerate solid food and ambulate soon after admission and appeared stable for discharge or transfer on September 21, 2019. Our physician reviewer found that the enrollee's condition did not meet Medicare criteria for inpatient 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 post stabilization inpatient care have not been met. Therefore, we decided that the Plan does not have to pay for the post stabilization inpatient care provided to the enrollee from September 21, 2019 to September 24, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested MRI.
You asked the Plan to pre-approve the MRI. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the requested MRI.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.You asked the Plan to pre-approve incontinence supplies. You say that the enrollee needs the requested incontinence wipes because of the enrollee's personal hygiene needs. You say that the enrollee has urine incontinence and you asked the Plan to reconsider their denial.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 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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on December 16, 2019 by an out of network (OON) provider.You asked the Plan to pay for an office visit. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that there is no approved referral from the member's primary care physician.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 an office visit provided on December 16, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foroffice visit services received from November 5, 2019 to December 17, 2019.You asked the Plan to pay forthe services. You say that there are no physicians with this provider's special skills in your area.The Plan denied your request. The Plan says the provider is not certified for Medicare.The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.The services at issue in this appeal were provided in a non-urgent, non-emergent situation. The provider has opted out of the Medicare program.Therefore, we decided that the Plan does not have to pay foroffice visit services received from November 5, 2019 to December 17, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay fora PAP test received on September 28, 2018.You asked the Plan to pay for the test. You say that two years and two months apart is not "too little time."The Plan denied your request. The Plan says that too little time has passed for another service of this kind to be allowed.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The plan has not substantiated their denial. The records show that the same services were received on July 29, 2016 and September 28, 2018 -the date of service at issue in this case. These dates are more than two years apart. The plan has not provided any evidence that a PAP test was received in between these two dates.Therefore, we decided that the Plan has to pay fora PAP test received on September 28, 2018.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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power mobility device.You asked the Plan to pre-approve a power mobility device. You say that your legs hurt to walk for long periods of time.The Plan denied your request. The Plan says a scooter is not medically necessary.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 file shows that your condition can be improved by a walker. Your assessment shows you are independent in all of your basic activities of daily living within your home and a four wheeled walker with a seat will meet your basic mobility needs. 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.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for physical therapy visits
You asked the Plan to waive the copayments for the physical therapy visits. You say that you were not asked to pay a copayment and you do not feel you owe these copayments. 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 $40 copayment per therapy type, per provider, per day for rehabilitation services. You have been asked to pay a $40 copayment for each of the physical therapy visits. The physical therapy visits fall within the "Outpatient rehabilitation 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 copayments for the physical therapy visits provided from August 9, 2019 to October 15, 2019.
Your complaint about not being satisfied with the 20-minute treatments 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 12 additional psychotherapy visits (90837).
You asked the Plan to pre-approve the psychotherapy services. You say that the services are medically necessary. The Plan denied your request. The Plan says rules for coverage were not met.
The Plan follows Medicare rules. Medicare rules say that outpatient mental health visits are covered when 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 psychotherapy services. Our reviewer says that the 12 additional visits are not medically necessary. Our physician reviewer found there is no documentation to support additional therapy. It does not appear to be reasonable or medically necessary as the enrollee has accepted limitations and strengths. The enrollee does not have new onset of symptoms but ongoing difficulty. 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 psychotherapy services have not been met. Therefore, we decided that the Plan does not have to pre-approve 12 additional psychotherapy visits (90837).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveAranesp (J0881).You asked the Plan to pre-approveAranesp. You say that Aranesp is medically necessary.The Plan denied your request. The Plan says coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Aranesp. Our reviewer says that Aranesp is not medically necessary in this case. Our physician reviewer found the enrollee does not have a diagnosis for which Aranesp is FDA approved for supported my major drug compendia. It is possible one of her medications is causing her anemia and at this point a trial off of them would be warranted. Use of Aranesp is not supported by the medical literature for anemia from pancytopenia.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Aranesp have not been met.Therefore, we decided that the Plan does not have to pre-approveAranesp (J0881).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the arthrocentesis and sacroiliac joint injection provided on February 13, 2020.You asked the Plan to waive the copayment for the arthrocentesis and sacroiliac joint injection. You say that you received the injection on the wrong side. You say that you shouldn't have to pay.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 $600 copayment per in-network visit for outpatient surgery.You have been asked to pay a $600 copayment for the arthrocentesis and sacroiliac joint injection. The arthrocentesis and sacroiliac joint injection 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 copayment for the arthrocentesis and sacroiliac joint injection provided on February 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora pneumatic compression device (E0652) with segmental pneumatic appliance (E0667).You asked the Plan to pay fora pneumatic compression device and appliance. You say that you request reversal of the denial of coverage so that the enrollee may begin daily treatment and prevent further complications/progression of her lymphedema.The Plandenied your request. The Plan says the enrollee does not meet the LCD criteria for an advanced lymphedema pump as there is no failed four week trial of a basic pneumatic compression device of either E0650 or E0651. The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least fourweeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses theappliance provided.Therefore, we decided that the Plan does not have to pay fora pneumatic compression device (E0652) with segmental pneumatic appliance (E0667).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveCPAP Mask Liners.You asked the Plan to pre-approveCPAP Mask Liners. You say that the liners are medically necessary.The Plan denied your request. The Plan says CPAP mask liners are not a covered item.The Plan must follow Medicare rules. Medicare rules say that a liner used in conjunction with a PAP mask is considered a comfort and convenience item and is not covered. We looked at the file and Medicare rules. The requested item is not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of CPAP Mask Liners have not been met.Therefore, we decided that the Plan does not have to pre-approveCPAP Mask Liners.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for Skilled Nursing Facility (SNF) care provided from December 14, 2019 to January 13, 2020.
You asked the Plan to pay for SNF care. You say that you are appealing. The Plan denied your request. The Plan says the denial of payment for these SNF services is correct, because the enrollee did not meet the Medicare criteria for SNF care on these dates of service.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee did not have skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a Skilled Nursing Facility (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 pay for Skilled Nursing Facility (SNF) care provided from December 14, 2019 to January 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an oximeter device (E0445).
You asked the Plan to pre-approve an oximeter device. You say that this equipment was recommended to you for you to have more control of your treatment and not have to be admitted due to pulse decreases. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that oximeters are not covered because they are monitoring devices that provide information to the treating practitioner to assist in managing the beneficiary's treatment. Based on this information, we decided that Medicare rules for coverage of an oximeter device have not been met. Therefore, we decided that the Plan does not have to pre-approve an oximeter device (E0445).
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 November 25, 2019 to December 2, 2019.You asked the Plan to waive the copayment for the inpatient hospital stay. You say that would like insurance to pay for the claim. 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 $320 copayment per day, days 1-5 and a $0 copayment per day, days 6-90 for each medically necessary covered inpatient stay. You have been asked to pay a $1,600 copayment for the inpatient hospital stay. ($320 x 5 = $1,600). 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 November 25, 2019 to December 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for home physical and occupational therapy provided from October 25, 2019 to November 6, 2019.
You asked the Plan to pay for the home physical and occupational therapy. The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 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 home physical and occupational therapy provided from October 25, 2019 to November 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power mobility device (K0108).You asked the Plan to pre-approve the power mobility device. You say that the current scooter you own has broken down several times.The Plan denied your request. The Plan says the current scooter was provided in 2019 and the record does not show it is irreparable.The Plan must follow Medicare rules. Medicare rules say that in the absence of program instructions, plans may  determine the reasonable useful lifetime of the equipment, but in no case can it be less than 5 years.We looked at the file and Medicare rules. The current power scooter was provided in September 2019. The record does not show it is damaged beyond repair. Based on this information, we decided that Medicare rules for coverage of the power mobility device have not been met.Therefore, we decided that the Plan does not have to pre-approve a power mobility device (K0108).