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

We decided that the Plan does not have to waive the coinsurance for the wrist/finger brace provided on October 15, 2019.You asked the Plan to waive the coinsurance for the wrist/finger brace. You say that the brace is overpriced.The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for each Medicare-covered durable medical equipment item.You have been asked to pay $71.57, which is 20% of the allowed amount for the wrist/finger brace. The allowed amount is $357.86 (20% x $357.86 = $71.57). The wrist/finger brace falls within the "Durable medical equipment (DME) and related supplies" 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 coinsurance for the wrist/finger brace provided on October 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the outpatient hospital services
You asked the Plan to waive the copayments for these services. You say that the enrollee has been overcharged. The Plan denied your request. The Plan says the copayments were 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $350 copayment for in-network outpatient hospital surgery.
The file shows that the enrollee presented to an outpatient hospital for wound debridement for 11 visits from March 12, 2019 to June 11, 2019. Per the contract with the Plan, there is a $350 copayment for in-network outpatient hospital surgery. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. However, the Medicare allowed amount for these services was $294.63 per visit. Given that the allowed amount was less than the $350 copayment, the enrollee has been asked to pay $294.63 per visit for these services.
Therefore, we decided that the Plan does not have to waive the copayments for the outpatient hospital services
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for comprehensive orthodontic services, braces (D8080) provided October 29, 2019. You asked the Plan to pay for the braces. You say that you are 2 months into 8 months of treatment of wearing braces. The TAP appliance you had been using caused misalignment of your bite and removal of 4 front teeth. The Plan denied your request. The Plan says this is not a covered benefit. 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 pay for comprehensive orthodontic services, braces (D8080) provided October 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services provided on July 26, 2018.
You asked the Plan to pay for the anesthesia services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services were filed untimely.
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 anesthesia services was not filed until August 6, 2019. 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 the anesthesia services provided on July 26, 2018.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve6 additional physical therapy visits.You asked the Plan to pre-approveadditional visits. You say that the enrollee's range of motion and strength need further improvement.The Plan denied your request. The Plan says the additional services are not medically necessary at this time.The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.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 additional visits. Our physician reviewer found that the enrollee has chronic back pain due to muscle spasm and thoracolumbarradiculitis. Treatments have includedcore strengtheningand homeexercise program implementation. Forback pain complaints, physical therapy is generally accepted as specific and effective therapy.Goals include reducing pain, restoring function, and educating regarding a home exercise program.In this case, there is no indication prior PT has served to provide sustained, significant improvement in pain and/or function. There is no indication that residual deficits could not be addressed via a home exercise program.Therefore, this request is deemed 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 additional visits have not been met.Therefore, we decided that thePlan does not have to pre-approve6 additional physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvefoot orthotics.You asked the Plan to pre-approvefoot orthotics. The Plandenied your request. The Plan says that the record does not show that the enrollee has diabetes.Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.  Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of orthotics for the enrollee's condition.Therefore, we decided that the Plan does not have to pre-approvefoot orthotics.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve100mg Nucynta tablets (J8499).You asked the Plan to pre-approvethe Nucynta. You say that you would like reconsideration because this drug is medically necessary for the treatment of the member's condition.The Plan denied your request. The Plan says Nucynta is intended for patient self-administration and is not a drug covered under Medicare Part B.The Plan must follow Medicare rules. The rules say that Medicare Part B generally doesnot 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-approve100mg Nucynta tablets (J8499).Benefits for the Nucyntamay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvepodiatry services.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or feet or have fungal nails. Records do not show that any of these conditions are present. 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-approvepodiatry services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe maxillarypartial denture provided on November 27, 2019.You asked the Plan to pay forthe maxillary partial denture. You say that your in-network dentist would not help you and you needed this service provided due to an upcoming vacation. You also say that you knew the rendering provider was out-of-network with your plan.The Plan denied your request. The Plan says this service is not a covered benefit.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 pay forthe maxillary partial denture provided on November 27, 2019.Your complaint about your dissatisfaction with your in-network provideris 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Fentanyl patches.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says self-administered drugs are not covered.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-approveFentanyl patches.Benefits for these servicesmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveMethotrexate tab, 2.5 mg.You asked the Plan to pre-approveMethotrexate. The Plan denied your request. The Plan says the enrollee's diagnosis is not one that is eligible for coverage of Methotrexate under Medicare Part B.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-approveMethotrexate tab, 2.5 mg.Benefits for Methotrexatemay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Heart Monitor device.
You asked the Plan to pre-approve the a Heart Monitor device. You say that the hemodynamic data are used by physicians for heart failure management and with the goal of reducing heart failure hospitalization. The Plan denied your request. The Plan says there is not enough medical evidence that shows the use of this device is helpful and safe.
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 a Heart Monitor device. Our reviewer says that the CardioMEMS Heart Monitor device is not considered medically reasonable and necessary. Our physician reviewer found therapy change based on data obtained from a device has been demonstrated in only one trial to help reduce hospital readmission compared to standard medical therapy. Moreover, concerns have been raised about potential bias in this trial calling into question the results. Therefore, the efficacy of the device is uncertain at this time according to leading authorities and is not recommended in current guidelines for the treatment of heart failure. The device is considered experimental or investigational. 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 a Heart Monitor device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Heart Monitor device.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical assistant services on a hysterectomy (58262 and 57260) provided on July 11, 2019.You asked the Plan to pay forsurgical assistant services. You say that this provider was the only assistant available at the time of the surgery.The Plan denied your request. The Plan says this provider is not eligible for payment on surgical assistant services.The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS.In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners.Therefore, we decided that the Plan does not have to pay forsurgical assistant services on a hysterectomy (58262 and 57260) provided on July 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean Epifix skin substitute.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules.Medicare rules say that Epifix is covered for use with diabetic foot ulcers and venous stasis ulcers only.We looked at the file and Medicare rules. The file does not show that you have a venous stasis ulcer or diabetic foot ulcer. 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-approvean Epifix skin substitute.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH).You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary.The Plan denied your request. The Plan says an alternative level of care is hospice care of long-term care.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is currently undergoing treatment at an ACH for multiple strokes in the setting of multiple baseline co-morbidities. The enrollee has received a tracheotomy and feeding tube. The enrollee is noted to have an extremely poor long-term prognosis. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long-term care 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 LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH)
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelongterm acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found you are currently undergoing treatment at an acute care hospital (ACH) for acute renal injury and heart block. You were transiently intubated/ventilated, but are no longer intubated/ventilated. There is no evidencethat you require services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring you to the LTACH. You can remain at the current ACH until such time no acute services are required. You can then be transferred/discharged to a lower level of care for any ongoing long term care (LTC) 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 LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from October 6, 2019 to October 8, 2019.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says the cost sharing has been applied correctly for the inpatient hospital admission.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $300 copayment per day, for days 1-5 for inpatient hospital care. The enrollee has been asked to pay a $600 copayment ($300 x 2 days) for inpatient hospital care. 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 the inpatient hospital care provided October 6, 2019 to October 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on November 22, 2019 by an out of network (OON) provider.You asked the Plan topay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services were rendered by an out-of-network provider without prior authorization.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 forthe medical services provided on November 22, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a respirator with filter cartridges provided November 12, 2019.
You asked the Plan to pay for the respirator and filters. You say that the mask is medically necessary due to your condition and occupation. The Plan denied your request. The Plan says the supplier is not a Medicare provider and these items are not a covered item.
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 pay for a respirator with filter cartridges provided November 12, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve CT scan of the chest and abdomen and a whole-body scan for the enrollee.You asked the Plan to pre-approve the scan. You say that this is necessary as the enrollee has undergone radiation therapy, and these tests were ordered to follow-up after this treatment.The Plan denied your request. The Plan says that there is a lack of medical necessity.The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 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 scan. Our reviewer says that the requested scans are medically reasonable and necessary. Our physician reviewer found in the usual case, these scans would not yet be medically necessary. However, the enrollee has a history of triple negative breast malignancy, meaning the likelihood of metastatic disease and/or recurrence is higher than the average patient. While there is no new symptom to suspect recurrence, careful vigilance to exclude same is necessary due to the tumor specifics. Metastatic disease may present early without clinical evidence to imply same.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 scan have been met.Therefore, we decided that the Plan has to pre-approve CT scan of the chest and abdomen and a whole-body scan for the enrollee.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.