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

We decided that the Plan does not have to pay for the lumbar-sacral orthosis and the knee orthosis provided on March 13, 2020.
You asked the Plan to pay for the lumbar-sacral orthosis (L0648)and the knee orthosis (L1833). You say that the orthoses were medically necessary. The Plan denied your request. The Plan says the records show the enrollee did not have an appropriate face-to-face encounter documented in the records to substantiate the need for the orthoses.
The Plan must follow Medicare rules. There are no medical records, around the date of the order, supporting medical necessity for the orthosis. Medicare rules say that items and services that are not medically necessary are not covered.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lumbar-sacral orthosis (L0648)and the knee orthosis (L1833) have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis and the knee orthosis provided on March 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tresiba Flex inj 100 unit.
You asked the Plan to pre-approve Tresiba Flex inj 100 unit. You say that the requested 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 Tresiba Flex inj 100 unit.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia for the enrollee.
You asked the Plan to pre-approve Prolia. You say that the enrollee has osteoporosis. The Plan denied your
request. The Plan says that it is not known if the enrollee has low blood vitamin D level or any other
disturbances of bone or mineral metabolism and if these have been treated effectively.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe
and effective and otherwise reasonable and 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 Prolia. Our reviewer says that Prolia is
not medically reasonable and necessary for the enrollee in this case. There is no documentation that Vitamin D
status has been assessed. The documentation does not support that Prolia is medically reasonable and necessary
for the patient. The documentation does not support that the Prolia is safe and effective for the patient. Our
physician reviewer found that the enrollee's condition does not meet Medicare criteria for Prolia.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to
pre-approve Prolia for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for a breast ultrasound (76641) provided on September 5, 2019.
You asked the Plan to pay for the ultrasound. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the submitted medical records do not contain sufficient documentation to support the procedure code's level of complexity.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 76641 is ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; complete. We asked our coder 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 ultrasound. Our reviewer says that CPT code 76641 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided do not include documentation to validate inspection of all the 4 quadrants and the retroareolar area of the breast, therefore 76641 cannot be verified. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ultrasound have not been met. Therefore, we decided that the Plan does not have to pay for a breast ultrasound (76641) provided on September 5, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the services provided to you on February 24, 2020.
You asked the Plan to pay for the services. The Plan denied your request.
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. Specifically, the Plan has not provided the case file for the requested services. Multiple attempts were made to obtain this information. Without supporting documentation, the Plan's denial cannot be substantiated. Therefore, we decided that the Plan has to pay for the services provided to you on February 24, 2020.
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approve IRF care. You say that the requested IRF admission is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.The Plan must follow Medicare rules. The rules say that IRF admission iscovered only when it is medically reasonable and necessary as described above.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 IRF care. Our reviewer says that the enrollee does not meet criteria for IRF admission. Our physician reviewer found the enrollee suffered a left femoral neck mid-cervical fracture status post total hip replacement. Co-morbid conditions include chronicobstructive pulmonary disease. Pain is controlled. The enrollee is hemodynamically stable, and hemogram is within acceptable parameters. Functionally, he remains at a contact guard assist/minimal assist for mobility, activities of daily living, and transfers while maintaining hip precautions.Records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a lesser level of care. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a lesser level of care. In this case, the member is mostly minimal assist for functional transfers and activities of daily living and a less intensive, longer duration of therapy will allow for measurable gains to be attainedwithin a reasonable, and predicted period. An IRF intensity is not warranted. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to waive the copayment for outpatient clinic visit (G0463) for services provided March 11, 2020.
You asked the Plan to waive the copayment for outpatient clinic visit. You say that you would like to appeal this claim you received because you feel there should be no copayment because you went to your PCP. The Plan denied your request. The Plan says that when you visit a provider you may be charged an additional fee. This fee reflects a trend in hospitals buying doctor's practices and additional fees to patient's bills. In those cases, the outpatient cost-share applies to the services. You should ask every provider's office you visit if you will charged an additional fee and if there is another office where you can see the provider without paying a fee.
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 does not say in clear and accurate terms how much you should expect to pay for a PCP visit in a clinic. There is no provision in the EOC for a $30 facility copayment if seen by the PCP in a clinic. We looked at your contract with the Plan. We did not see where the contract says enrollees must pay $30 copayment if seen by the PCP in a clinic. There is no way that an enrollee could have reasonably expected to know that a $30 copayment would apply to a PCP service they received in a clinic. The Plan contract does not clearly say how much enrollees must pay for a PCP visit in a clinic. The only reference to a $30 copayment in the Cost-Sharing guide is for a specialist office visit, which is not the service provided as the enrollee saw their PCP and this is not listed under the "outpatient cost-share. This means that the Plan did not follow Medicare rules for disclosure of cost sharing information. Therefore, we decided that the Plan has to waive the copayment for outpatient clinic visit (G0463) for services provided March 11, 2020.
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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided June 10, 2019 to June 14, 2019.
You asked the Plan to pay for the SNF services. You say that you feel that the plan should cover for the SNF services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided June 10, 2019 to June 14, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional home health services.You asked the Plan to pre-approve home health services. You say that the enrollee says his condition continues to get worse.The Plan denied your request. The Plan says the additional services are notneeded as the enrollee's medical problems appear stable.The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.The file shows that the plan pre-approved 3 home health nursing visits, 3 physical therapy visits, and 2 aide visits. We asked our physician reviewer to carefully review the case file and apply the relevantMedicare rules to determine if the Plan was correct in denying the request to pre-approve additional services. Our physician reviewer found that the records do not show that the remaining skilled nursing services are required to effectively provide treatment or services in order to improve the enrollee's condition, or to prevent deterioration. There is no evidence of complex wound care. His medical condition is stable with chronic conditions. He has had disease and medication education. The records do not show that the remaining skilled therapy services are required to effectively provide services in order to improve the enrollee's level of function, or to perform a maintenance program to maintain his level of function or prevent deterioration. Without the need for ongoing skilled nursing or skilled therapy, the services do not meet criteria for home health aide 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 home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve additional home health services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray (73502) provided February 14, 2019.
You asked the Plan to pay for the x-ray. You say that the service was medically necessary. The Plan denied
your request. The Plan says the claim is a duplicate.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT code 73502 is not supported in the medical record. Specifically, the record shows the claim is
a duplicate of another claim submitted for the same date of service. There is no modifier to denote a repeat
service. Based on this information, we decided that Medicare rules for coverage of the x-ray have not been met.
Therefore, we decided that the Plan does not have to pay for an x-ray (73502) provided February 14, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional mileage.You asked the Plan to pre-approve additional mileage. You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says the transportation benefit only covers up to 50 miles per one-way trip.Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 24 one-way transportation trips per year, not to exceed 50 miles per one-way trip. We looked at your request, the records in the case file, and the rules. The file shows you are requesting a total of 61 miles per one-way trip. Your contract with the Plan clearly says you are only covered for up to 50 miles per one-way trip.Therefore, we decided that the Plan does not have to pre-approve additional mileage.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an injection, denosumab, 1 mg (J0897) provided September 9, 2019.
You asked the Plan to waive the copayment for the injection. You say that you were never informed you would a copayment of 20%. This would be a hardship for you and as a courtesy request the charges to be taken care of. The Plan denied your request. The Plan says this claim was processed correctly per the plan 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). Your contract with the Plan clearly says that you must pay 20% coinsurance for chemotherapy and other drugs covered by Medicare part B. for Medicare Part B prescription drugs. You have been asked to pay $229.25 (the total cost approved $1,146.24 x 20%) for the injection. The injection falls within the Medicare Part B prescription drugs 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 an injection, denosumab, 1 mg (J0897) provided September 9, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral-periapical x-ray provided on March 4, 2020.
You asked the Plan to pay for the intraoral-periapical x-ray. You say that the x-ray was necessary for the
dentist to determine your dental situation. You say that this should be covered regardless of frequency
limitations. The Plan denied your request. The Plan says only four periapical x-rays are allowed in a 12 month
period.
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 Plan also has a maximum benefit
of 4 periapical x-rays in a 12-month period. The Plan paid for 4 periapical x-rays on February 7, 2020, which
exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the intraoral-periapical xray
provided on March 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical equipment purchased from January 4, 2020 to January 22, 2020 from an out of network provider.You asked the Plan to pay forthe medical equipment purchased from an out of network provider. You say that you have balance issues, intermittent dizziness and have fallenso you purchased the equipment. The Plan denied your request. The Plan says the purchase does not meet any of the required criteria for the Plan to cover the out of network equipment.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 at issue in this appeal. The Plan did not pre-approve the items at issue. We found no exception that would require the Plan to pay for these items.Therefore, we decidedthat the Plan does not have to pay forthe medical equipment purchased from January 4, 2020 to January 22, 2020 from an out of network provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair, group 2 heavy-duty (K0825).
You asked the Plan to pre-approve a power wheelchair, group 2 heavy-duty. You say that the requested item is
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria
has not been met.
The Plan follows Medicare rules. Medicare rules say that a power wheelchair is covered if specific criteria is
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 a power wheelchair, group 2 heavy duty.
Our reviewer says that the item is not medically necessary. Our physician reviewer found in this case, you
are not noted to have an inability to utilize a lesser device (lightweight manual wheelchair, standard manual
wheelchair, or use of a walker). Therefore, this request is 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 a power wheelchair, group 2 heavy-duty have not been met. Therefore, we
decided that the Plan does not have to pre-approve a power wheelchair, group 2 heavy-duty (K0825).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the gym membership purchased August 30, 2019.
You asked the Plan to pay for gym membership. You say that you paid $570.28 for your 2019 and 2020 gym membership on August 30, 2018. You thought you would be reimbursed for the cost of membership during the year it was used regardless of when it was paid. The Plan denied your request. The Plan says the claim was processed correctly. The claim was submitted February 1, 2019 and the Plan reimbursed $240 for the gym membership fee on February 20, 2019.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The date of service for this benefit is the date you make payment. For example, if you pay on December 15 for a gym membership that starts January 1, December 15 is the date of service. The Plan's rules for coverage of gym benefits have not been met because the benefit is based on the date the service was purchased or obtained. Therefore, we decided that the Plan does not have to pay for the gym membership purchased August 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wheelchair ramp/lift.
You asked the Plan to pre-approve wheelchair ramp/lift. You say that you need this device for getting in and out of your home without assistance. The Plan denied your request. The Plan says the denial of authorization for this item is correct, because this item is not primarily medical in nature and is 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 a wheelchair ramp/lift.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crowns (D2740) for tooth #'s 2 and 3 provided on
January 21, 2020.
You asked the Plan to pay for the crowns (D2740) for tooth #'s 2 and 3. You say that you were informed the
copayment would be $250 for each tooth. You say that the cost is a burden and you request any financial help
you can receive. The Plan denied your request. The Plan says the service is not a covered benefit for molar
teeth.
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 crowns are not listed as a covered
benefit for molar teeth. Therefore, we decided that the Plan does not have to pay for the crowns (D2740) for
tooth #'s 2 and 3 provided on January 21, 2020.