Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous lumbar decompression services.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the submitted documentation does not support a covered indication.
The Plan must follow Medicare rules. Medicare rules say that PILD will be covered by Medicare when provided in a clinical study. We looked at the file and Medicare rules. The documentation in the case file does not show that the requested services will be provided in an approved clinical study. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous lumbar decompression services.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to waive the deductible forthe specialist office visits, the glucose monitoring, and the laboratory tests. We decided that the Plan does not have to waive the coinsurance forthe specialist office visits, the glucose monitoring, and the laboratory tests.You asked the Plan to waive the deductible forthe specialist office visits, the glucose monitoring, and the laboratory tests. You say that you were told your doctor was in-network and that laboratory services were covered with no copayments or deductible. You say you cannot afford to pay these bills.The Plan says that you have been charged the correct cost sharing amount.We decided that the Planhas to waive the deductible forthe specialist office visits, the glucose monitoring, and the laboratory tests. The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles, and coinsurance). The records show that the deductible does not apply towards physician specialist services, outpatient diagnostic procedures, tests, and lab services.The Plan says that you must pay a total of $824.53 towards the deductible for the specialist office visits, the glucose monitoring, and the laboratory tests. Based on the plan contract, however, you cannot be asked to pay more than a total of $371.04coinsurancefor the specialist office visits, the glucose monitoring, and the laboratory tests. Therefore, we decided that the Plan has to waive the deductible and apply the coinsurance for the specialist office visits, the glucose monitoring, and the laboratory tests from a total of $824.53 to a total of $371.04. We also decided that the Plandoes not have to waive the coinsuranceforthe specialist office visits, the glucose monitoring, and the laboratory tests.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 45% coinsurancefor out-of-network specialist office visits, out-of-networkglucose monitoring, and theout-of-network laboratory tests.See chart below.Date of ServiceServicesAllowed AmountCoinsuranceMember LiabilityJanuary 2, 2020Glucose monitoring$146.4445%$65.89January 2, 2020Specialist office visit$145.4945%$65.47January 16, 2020Specialist office visit$145.4945%$65.47January 16, 2020Laboratory tests$387.1445%$174.21Total$371.04Therefore, we decided that the Plandoes not have to waive the coinsuranceforthe specialist office visits, the glucose monitoring, and the laboratory tests.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 therewas 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: Lab
Decision: Favorable

We decided that the Plan has to waive the deductible for the laboratory work provided on January 15, 2020. You asked the Plan to waive the deductible for the laboratory work. You say that you were told laboratory services were covered with no copayments or deductible The Plan denied your request. The Plan says that 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. Your contract with the Plan says that enrollees must pay a $0 copayment for in-network Medicare-covered lab services. The Plan says you must pay $3 towards your deductible for the laboratory work. Based on the Plan contract, however, you cannot be asked to pay more than a $0 copayment for the laboratory work. The record shows that the provider is a contracted provider. Therefore, we decided that the Plan has to waive the deductible for laboratory work provided on January 15, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug Morphine provided on December 12, 2019.You asked the Plan to pay for the compounded drug. You say that the Plan should pay this claim.The Plan denied your request. The Plan says the medical records indicate that a compounded drug was administered and J7999KD would be a more appropriate code.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 J2274 is for Injection, morphine sulfate, preservative-free for epidural or intrathecal use. We find that CPT code J2274 is not supported in the medical record. Specifically,the drug is used in an implantable infusion pump and the CPT code is incorrect on the claim.Based on this information, we decided that Medicare rules for coverage ofthe compounded drug have not been met.Therefore, we decided that the Plan does not have to pay forthe drug Morphine provided on December 12, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from February 7, 2020 to February 12, 2020. You asked the Plan to pay for the skilled nursing services. You say that the enrollee was sick during this time and this is a financial burden to her. The Plan denied your request. The Plan says Medicare guidelines are not met because there is no skilled nursing or skilled physical and occupational therapy needs, because the enrollee reached her maximum potential. The Plan also says that the enrollee's needs could be met at a lower level of care. 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 the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily 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 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 the skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from February 7, 2020 to February 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99213) and care management (99484) provided on May 18, 2020 by an out of network (OON) provider.You asked the Plan to pay for an OON office visit and care management. You say that you did not realize this provider was not in-network.The Plan denied your request. The Plan says these services were not authorized.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan 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 (99213) and care management (99484) provided on May 18, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for fundus photography (92250) and visual field examination
(92082) provided on December 30, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the vision services. You say that your office is not on the providers list and you
were not aware a pre-authorization was needed for this enrollee to be seen in your office. The Plan denied your
request. The Plan says enrollee's must receive their medical services from an in-network provider. The plan
says that non-emergent services with non-contracted providers require prior-authorization prior to services
being rendered.
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 fundus photography (92250) and visual field
examination (92082) provided on December 30, 2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve shoulder surgery services.
You asked the Plan to pre-approve the requested services. You say that you cannot lift your arm above your head without it hurting. The Plan denied your request. The Plan says you have not met the required criteria.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file, and Medicare rules. In this case, there were insufficient records provided to show that the requested surgery services are medically reasonable and necessary to treat your condition. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve shoulder surgery services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair and accessories. You asked the Plan to pre-approve a Group 3 power wheelchair and accessories. You say that the enrollee desires to be active both inside and outside of the facility. The Plan denied your request. The Plan says the enrollee's needs can be met with a manual wheelchair or a lower level power wheelchair. The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF to be a home. Records show that a Group 3 power wheelchair and accessories is being requested for use in a SNF. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair and accessories.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the non-preferred brand of meter and test strips.You asked the Plan to pre-approve the non-preferred brand of meter and test strips. You say that you want the non-preferred brand of test strips.The Plan denied your request. The Plan says there is no medical reason documented that you are medically unable to use the Plan preferred test strips.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. There is no physician documentation that the non-preferred brand is necessary to avoid an adverse medical outcome. Based on this information, we decided that Medicare rules for coverage of the non-preferred brand of test strips have not been met.Therefore, we decided that the Plan does not have to pre-approve the non-preferred brand of meter and test strips.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve continued skilled nursing facility (SNF) services June 6, 2020 and
forward.
You asked the Plan to pre-approve SNF care. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says that the requested services are not medically necessary.
The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will
stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before
the last covered day. This notice must include a description of the enrollee's right to an appeal.
We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or
more days before June 5, 2020. The Plan must pay for SNF services until the 100-day SNF care benefit is
exhausted or daily skilled care is no longer needed and proper notice is issued. Therefore, we decided that the
Plan has to pre-approve continued skilled nursing facility (SNF) services June 6, 2020 and forward.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for assisted living provided from December 4, 2019 to
December 31, 2019.
You asked the Plan to pay for assisted living. You say that you disagree with the Plan's denial and feel that this
should be reimbursed completely. The Plan denied your request. The Plan says the denial of payment for these
services is correct, because this provider is not eligible to participate in Medicare and custodial care services
are not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that to receive payment for covered Medicare items
or services, a provider must be enrolled in the Medicare program.
We looked at the file and Medicare rules. The servicing facility is an assisted living, memory care, and
independent living community which is not eligible to participate in Medicare. Based on this information, we
decided that Medicare rules for coverage of assisted living have not been met. Therefore, we decided that the
Plan does not have to pay for assisted living provided from December 4, 2019 to December 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for the office visit (99203) provided on
March 25, 2020.
You asked the Plan to issue reimbursement for the office visit. You say that you are requesting a
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says this service is not
a covered benefit under your contractual policy.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation.
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that
the Plan does not have to issue reimbursement for the office visit (99203) provided on March 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99202) provided on February 10, 2020.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit under
your contractual policy.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation.
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that
the Plan does not have to pay for the office visit (99202) provided on February 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the removal of torus mandibularis (D7473).
You asked the Plan to pre-approve the removal of torus mandibularis. You say that you need this procedure in
order to restore normal mandibular function. The Plan denied your request. The Plan says this service is not
covered under your benefit package.
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
removal of torus mandibularis (D7473).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110).
You asked the Plan to pre-approve the complete maxillary denture. You say that your dentures cracked and
were not fixed correctly. The Plan denied your request. The Plan says this service exceeds your benefit
limitation.
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, complete or partial dentures are limited
to up to 1 set every 5 calendar years. The record shows that you received a complete maxillary denture (D5110)
on November 16, 2017 and your maxillary dentures benefit has been exhausted. Therefore, we decided that the
Plan does not have to pre-approve a complete maxillary denture (D5110).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair power seat elevation
system, electronic connection, base upgrade, color kit, reach transfer package, power seat height, multiple seat
function, arm rest pouch and USB charger.
You asked the Plan to pre-approve a power seat elevation system, electronic connection, base upgrade, color
kit, reach transfer package, power seat height, multiple seat function, arm rest pouch and USB charger. You say
that you need a Group 3 power wheelchair and accessories. The Plan denied your request. The Plan says these
accessories 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 items at issue in this appeal do not serve a purpose that is primarily medical in nature. They are available
to the general public and would be helpful even to those who are not sick or injured. The electronic upgrades
cannot be covered as it is not medically necessary to control the approved power options through the joystick.
Therefore, we decided that the Plan does not have to pre-approve the Group 3 power wheelchair power seat
elevation system, electronic connection, base upgrade, color kit, reach transfer package, power seat height,
multiple seat function, arm rest pouch and USB charger.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CGM System.
You asked the Plan to pre-approve a continuous glucose monitor. You say that this is the only effective device
for your sugar. The Plan denied your request. The Plan says a CGM is not covered by Medicare when an
enrollee is not on insulin.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We looked at the file and Medicare rules. The record shows you are not insulin treated so you do not meet the
Medicare coverage criteria for a CGM. Based on this information, we decided that Medicare rules for coverage
of a continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to preapprove
a CGM System.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a manual wheelchair and accessories.
You asked the Plan to pre-approve a manual wheelchair and accessories. You say that the enrollee slides out of
the standard chair provided by the facility. The Plan denied your request. The Plan says the wheelchair request
is for a long term care facility resident.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate
and needed for use inside the home. Medicare does not consider a SNF to be a home.
Records show that a manual wheelchair and accessories is being requested for use in a SNF. Therefore, we
decided that the Plan does not have to pre-approve a manual wheelchair and accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on January 31, 2020 by an out of
network (OON) provider.
You asked the Plan to pay for physician services. 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 the member's primary care physician did not refer these services.
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 physician services provided on January 31, 2020
by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve specialist services to be provided by an out of network
(OON) provider.
You asked the Plan to pre-approve specialist services. You say that this is discriminate against you because of
your age and diagnosis. The Plan denied your request. The Plan says there are in-network providers available.
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
specialist services to be provided by an out of network (OON) provider.