Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve consultation and treatment. 
 
You asked the Plan to pre-approve consultation and treatment. You say that the specific service being requested 
is for adult day care. This is a benefit you were told by a plan representative is a payable benefit with prior 
authorization. The Plan denied your request. The Plan says the requested service is unspecified and there is 
insufficient information to determine medically necessity. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. There is no procedure code (CPT) code identifying the type of service being 
requested. There is no information how the requested unspecified service will help your condition. 
 
We looked at  the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of consultation and treatment have not been met. Therefore, we decided that the Plan does not have to 
pre-approve consultation and treatment.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wheel accent colors, a shroud assy, and a USB charger 
(K0108). 
 
You asked the Plan to pre-approve wheel accent colors, a shroud assy, and a USB charger. You say that these 
items were approved for your previous wheelchair. The Plan denied your request. The Plan says these items are 
not covered by Medicare. 
 
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 wheel accent colors, a shroud assy, and a USB charger 
(K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Group 2 single power option power wheelchair and attachments for the enrollee.You asked the Plan to pre-approve these services. You say that this is medically necessary for the enrollee.The Plan denied your request. The Plan says that there is no documentation justifying the power chair and the power tilt option.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 requested items/services are not considered medically reasonable and necessary in this case. The documentation does not support that the patient meets coverage criteria for a power tilt or a power recline seating system. The documentation indicates the patient has a mobility deficit but the 5/12/20 mobility evaluation states the patient is bed bound and cannot walk. This conflicts with the physical therapy notes that states that the patient was using a walker in PT on 6/29/20. The documentation does not clearly indicate a detailed neuromuscular evaluation of the upper extremities indicating objective strength, range of motion measures. It is not clear why the patient can operate a rolling walker but not a manual wheelchair or why this patient's mobility deficit cannot be appropriately resolved with a manual wheelchair. There is no evidence this patient needs a drive control interface other than a hand or chin operated joystick or needs a power tilt or power recline seating system. The patient's current functional level should allow him to provide effective weight shifts. It is not clear that the mobility evaluation was performed by a therapist without financial relationship with the supplier. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for these services.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 Group 2 single power option power wheelchair and attachments for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300). 
 
You asked the Plan to pre-approve a power seat elevation system. You say that the enrollee needs this. The 
Plan denied your request. The Plan says this is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature (E2300) and 
power standing feature (E2301) are non-covered because they are not primarily medical in nature. 
 
We looked at the file and Medicare rules. The requested item is excluded from Medicare coverage. Based on 
this information, we decided that Medicare rules for coverage of a power seat elevation system have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system (E2300).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee's needs are met with BiPAP. 
 
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 the device. Our reviewer says that the 
requested device is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee was ordered a home ventilator in 2014. The records from that time note a hospitalization for 
dyspnea, which responded to BiPAP.  Evidence of an abnormal ABG, a restrictive thoracic disease or a 
neuromuscular disease is not present. Recently, the ventilator has been recommended for ongoing treatment of 
OSA. No sleep study reports have been submitted for review. There is no evidence that the enrollee tried and 
failed CPAP or BiPAP. As such, the documentation does not show that the enrollee meets criteria for use of a 
home ventilator (E0466). 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a home ventilator for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lightweight battery-operated scooter. 
 
You asked the Plan to pre-approve the electric scooter. You say that the durable medical equipment is 
medically necessary. The Plan denied your request. The Plan says the clinical information received states that 
you are able to do activities of daily living without limitations and are able to drive without limitations. 
 
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 electric scooter. Our physician 
reviewer found the documentation does not support that the patient has a mobility limitation that significantly 
impairs her ability to participate in one or more mobility-related activities of daily living (MRADLs) such as 
toileting, feeding, dressing, grooming, and bathing in customary locations in the home. The documentation 
does not reveal why any mobility limitation the patient may have cannot be sufficiently and safely resolved by 
the use of an appropriately fitted cane or walker although the patient's physician evaluation revealed normal 
gait and station on April 14. The documentation does not reveal a home evaluation indicating the patient can 
safely navigate the requested power mobility device (PMD) in the home. 
 
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 electric scooter have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a lightweight battery-operated scooter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office consultations to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve these OON services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested services can be provided by a network 
provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
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 
office consultations to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a standard walker. 
 
You asked the Plan to pre-approve the walker. You say that an incorrect height walker was ordered by the 
previous physical therapist. The Plan denied your request. The Plan says this 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 the walker. Our reviewer says that the 
requested walker is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the documentation does not indicate that your current walker is unsafe, and that your mobility deficit 
cannot be resolved with the current walker. You have a walker and the medical progress notes do not support 
that you require an additional walker or that your current walker is not able to meet your functional needs. 
 
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 walker have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a standard walker.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the core buildup, including any pins when required (D2950) for tooth #30.
You asked the Plan to pre-approve the core buildup. The Plan denied your request. The Plan says this service is not covered.
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 the core buildup, including any pins when required (D2950) for tooth #30.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve these OON services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested services can be provided by a network 
provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
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 
an office visit to be provided by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided to the enrollee on January 21, 2020.
You asked the Plan to waive the copayment for ambulance services. You say that at no time were you told that the enrollee would be responsible for paying a portion of the ambulance service. The Plan denied your request. The Plan says the claim was processed accordingly with the member's 2020 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that the enrollee received ambulance services on January 21, 2020. The enrollee is asked to pay a $220 copayment for ambulance services. The enrollee's EOC says that enrollees must pay a $220 copayment for each one-way Medicare-covered ground trip. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance services provided to the enrollee on January 21, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy provided on May 
29, 2020. 
 
You asked the Plan to waive the copayment for colonoscopy. You say that you should not be responsible for a 
copayment because this was a failed colonoscopy and the provider could not get any useful information. The 
Plan denied your request. The Plan says the copayment amount you are being charged is correct. 
 
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 $300 
copayment for diagnostic colonoscopy at an ambulatory surgical center.  
 
You have been asked to pay $300 copayment for colonoscopy. This colonoscopy 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 a diagnostic colonoscopy provided on May 29, 
2020.
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 January 15, 2020 to January 17, 2020.
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that this bill is a financial hardship. 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 20% coinsurance per admission for inpatient hospital care. You have been asked to pay $1,983.58 which is less than the standard 20% coinsurance amount for the inpatient hospital stay. The inpatient hospital stay falls within the "Inpatient hospital care" benefit category. The record shows that you have met your $2,500 maximum out-of-pocket amount.
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 January 15, 2020 to January 17, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the TAVR procedure to be provided by the out-of-
network facility. 
 
You asked the Plan to pre-approve the TAVR procedure. You say that you would prefer this procedure be done 
by an experienced team with a proven track record. The Plan denied your request. The Plan says the services 
are available in-network. 
 
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. 
 
We looked at the file and Medicare rules. 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 the TAVR procedure to be provided by the out-of-
network facility. Therefore, we decided that the Plan does not have to pre-approve the TAVR procedure to be 
provided by the out-of-network facility.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair (K0800). 
 
You asked the Plan to pre-approve a power wheelchair. You say that your previous wheelchair no longer 
functions. The Plan denied your request. The Plan says your mobility limitation can be resolved with a walker. 
 
The Plan must follow Medicare rules. Medicare rules say that all of the above-listed criteria must be met for a 
power mobility device to be 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 a power wheelchair. Our reviewer says 
that the requested power wheelchair is not medically necessary. Our physician reviewer found that while the 
submitted medical records show that you have a personal mobility deficit, they do not reveal that it impairs 
participation in MRADLs within the home. The documentation does not reveal why your mobility deficit is 
unable to be helped by a walker, cane or manual 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 power wheelchair have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power wheelchair (K0800).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from January 17, 2020 through January 29, 2020.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found there was no information documented on admission that would justify admission in this case. The patient was noted to be stable. Patient has dementia. Patient should have been put in Observation and if social and medical issues did not resolve, then admission would have been next step. There was not anything documented on admission that would justify admission. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from January 17, 2020 through January 29, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the CT, abdomen and pelvis; without 
contrast material (74176) provided on April 1, 2020. 
 
You asked the Plan to waive the copayment for the CT scan. You say that you are appealing your cost-share 
responsibility for the services you received. The Plan denied your request. The Plan says the claim was 
processed accordingly with your 2020 EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
Review of the file show that you received the CT scan on April 1, 2020. You are asked to pay a $150 
copayment for the CT scan. Your EOC states that enrollees must pay a $150 copayment for all other diagnostic 
and nuclear medicine radiological services. 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 CT, 
abdomen and pelvis; without contrast material (74176) provided on April 1, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care, evaluation and management of the critically ill 
or critically injured patient; first 30-74 minutes (99291) provided to the enrollee on February 13, 2019. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says Medicare denies a claim if it is not received by the plan within 12 months or 1 calendar 
year from the date when the services were rendered. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the services was not filed until April 29, 2020. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for critical care, evaluation and management of the critically ill or critically injured 
patient; first 30-74 minutes (99291) provided to the enrollee on February 13, 2019.