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

We decided that the Plan does not have to pre-approve a wheelchair transit system.You asked the Plan to pre-approve a wheelchair transit system. You say that the transit system is needed for community use. The Plan denied your request. The Plan says a transit system is only useful outside the home and therefore not covered.The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home. A transit system allows the wheelchair to be transported in a variety of vehicles. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home.Therefore, we decided that the Plan does not have to pre-approve a wheelchair transit system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe knee orthosis and suspension sleeve provided on February 13, 2019.You asked the Plan to pay forthe knee orthosis (L1851) and suspension sleeve (L2397). You say that the orthosis was medically necessary.The Plan denied your request. The Plan says rules for telehealth services have not been met.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay forthe knee orthosis and suspension sleeve provided on February 13, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on August 5, 2019.
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on August 5, 2019.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Abobotulinumtoxina for enrollee.You asked the Plan to pre-approve Abobotulinumtoxina. The Plan denied your request. The Plan says that the medication is not medically necessary for the enrollee's condition.The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Abobotulinumtoxina. Our physician reviewer found that the enrollee developed a parotid fissure after left superficial parotidectomy performed for a Warthlin's tumor. Treatment with antibiotic has not been successful. There is persistent sialorrhea.The requested use of the requested drug is not FDA-approved for the enrollee's diagnosis. The requested use of the drug is listed as an off-label use in the Medicare Compendia.The documentation does support that the requested drug is medically reasonable and necessary for the enrollee.The documentation does support that the requested drug is safe and effective for the enrollee.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Abobotulinumtoxina have been met.Therefore, we decided that the Plan has to pre-approve Abobotulinumtoxina for 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.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says that the enrollee is not yet full weight bearing and is not ready to participate in three hours of daily therapy.The Plan must follow Medicare rules. The rules say that IRF admission is covered 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 physician reviewer found that you were admitted to the acute care hospital with a displaced fracture of the lateral right seventh rib, displaced intertrochanteric right femur fracture, and mildly displaced fracture through the distal diaphysis of the left femur. Yourhospital course was complicated by a right lower extremity deep vein thrombosis with placement of an inferior vena cava filter. You havemultiple complex medical conditions. Due to yourorthopedic precautions,there would be an expected need to modify yourtreatment in order to maximize yourcapacity to benefit from rehabilitation. You requirephysical therapy for mobility and occupational therapy for remaining activities of daily living and adaptive equipment.You hadpreviously been independent and arenow unable to perform essential activities of daily living such as bed mobility or transfer without assistance. Yourpain has been controlled, and havean increased functional mobility tolerance for upright activities. Youwould be expected to be able to fully participate from the required intensity of an acuterehabilitation therapy program.You havetherapy and medical needs that meet criteria for acute level rehabilitation. Care at a lower level would not effectively meet yourrehabilitation needs.We looked at this physician's review, the file, and Medicarerules. Based on this information, we decided that Medicare rules for coverage of IRF care have been met.Therefore, we decided that the Plan has to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for endodontic therapy D3310) provided November 5, 2019.You asked the Plan to pay for the dental services. You say that you had an abscessed tooth and decided to seek treatment with your provider you've been seeing for 35 years. You feel payment should be covered under emergent treatment or oral surgery.The Plan denied your request. The Plan says the frequency limit has been exceeded for this service 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. Records show that you received endodontic treatment on August 1, 2018. The health plan contract specifically says this service is only covered once year.Therefore, we decided that the Plan does not have to pay for endodontic therapy D3310) provided November 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe Holter Monitoring provided on July 8, 2019 by an out of network provider.You asked the Plan to pay. You say that the enrollee's physician referred the enrollee.The Plan denied your request. The Plan says there is no valid referral for this service.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 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 provided on July 8, 2019 by an out of network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that you were in Florida when you started to feel unwell. You briefly passed out and when you came to, someone was taking your pulse and had called for an ambulance. You say that the responders got you into the ambulance and checked your vitals and blood sugar levels. You stated that by the time the responders had arrived you had already drank some orange juice and you were starting to feel better. You say that you were told that this service would be covered under your policy. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on August 5, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for end stage renal disease (ERSD) services (90999, A4657, J1756, J0887, and J1580) provided from December 3, 2018 to December 31, 2018.You asked the Plan to pay for ESRD services. You say that these services should be covered.The Plan denied your request. The Plan says these services were billed without an appropriate modifier on the last hemodialysis session of the month.The Plan must follow Medicare rules. Medicare rules say that ESRD claims for hemodialysis must indicate the type of vascular access used for the delivery of the hemodialysis at the last hemodialysis session of the month using one of the codes listed above on the latest line item date of service billing for hemodialysis revenue code 0821. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ESRD services have not been met. Specifically, this claim was billed without the required modifier on the last hemodialysis session of the month.Therefore, we decided that the Plan does not have to pay for end stage renal disease (ERSD) services (90999, A4657, J1756, J0887, and J1580) provided from December 3, 2018 to December 31, 2018
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hydrocodone/APAP for the enrollee.
You asked the Plan to pre-approve this drug. You say that this medication has been effective for the enrollee. The Plan denied your request. The Plan says that this is not covered by the Plan.
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 Hydrocodone/APAP for the enrollee.
Benefits for this drug may be available under Medicare Part D. Contact the 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 pay for acupuncture services (97810 and 97811) provided on August 29, 2019.You asked the Plan to pay for acupuncture services. You say that this is a covered benefit.The Plandenied your request. The Plan says acupuncture is not covered by Medicare or the Plan.The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare.The services at issue in this appeal are acupuncture services.Therefore, we decided that the Plan does not have to pay foracupuncture services (97810 and 97811) provided on August 29, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee x-ray provided on October 19, 2019.
You asked the Plan to pay for the knee x-ray. You say that the provider is not paid by hospice. You say that the
service is not related to the hospice diagnosis. The Plan denied your request. The Plan says Original Medicare
is responsible for payment.
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 knee x-ray provided on October 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics.You asked the Plan to pay for foot orthotics. You say that you have been having swelling in your knee and you had an MRI for it. You say that after speaking with your doctor, he recommended trying the foot orthotics as an alternative to other possible procedures. You stated that you thought the orthotics would be partially covered by the Plan as you are trying to exhaust all efforts prior to the need of a potential future procedure.The Plan denied your request. The Plan says this item is not a covered benefit. 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 you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition.Therefore, we decided that the Plan does not have to pay for foot orthotics.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forthe spinal injections provided from September 19, 2019 to October 16, 2019.You asked the Plan to waive the copayments forthe spinal injections. You say that you were not in a hospital so you were not aware you would be charged a $395 copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $395 copayment for surgery services at an in-network outpatient hospital. You have been asked to pay a $395 copayment for each of the spinal injections. The spinal injections fall within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows you were billed by the outpatient hospital.This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments forthe spinal injections provided from September 19, 2019 to October 16, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lupron Depot inj 30mg.
You asked the Plan to pre-approve Lupron Depot inj 30mg. You say that the requested medication is necessary.
The Plan denied your request. The Plan says coverage criteria is not met since the medication does not fall
under Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Lupron Depot inj 30mg.
Benefits for Lupron Depot inj 30mg may be available under Medicare Part D. Contact the Plan that administers
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.You asked the Plan to pre-approve IRF care. You say that this is medically necessary.The Plan denied your request. The Plan says the care could be received in another setting.The Plan must follow Medicare rules. The rules say that IRF admission is covered 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 requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the enrollee's medical status requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional therapy of PT and OT but the enrollee's functional status does not require this on an intensive rehabilitation facility therapy program level in an IRF.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-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the Caire Freestyle Comfort Portable Concentrator purchased  on July 17, 2019.
You asked the Plan to reimburse you for the portable oxygen concentrator. You say that you needed the portable oxygen concentrator because the tanks you have are too heavy to carry. The Plan denied your request. The Plan says the Plan cannot pay for purchased oxygen equipment.
The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would benefit from the use of portable oxygen in the home. Medicare rules say that only rented oxygen equipment is eligible for coverage. We looked at this physician's review, the file, and Medicare rules. Purchased oxygen equipment is statutorily non-covered by Medicare. Based on this information, we decided that Medicare rules for coverage of the portable oxygen concentrator have not been met. Therefore, we decided that the Plan does not have to reimburse you for the Caire Freestyle Comfort Portable Concentrator purchased on July 17, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you forthe comprehensive oral evaluation (D0150), the panoramic x-ray (D0330), the initial periapical x-ray (D0220), the 3 additional periapical x-rays (D0230), and the surgical extraction (D7140 x 8) provided from July 9, 2019 to September 17, 2019 by the out of network provider.You asked the Plan to reimburse you forthe dental services. You say that if you had known the provider was out of network, you would not have seen her.The Plan denied your request. The Plan saysservices that you receive out of network are not covered. The Plan also says that the provider in this case is not a network provider.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, dental services that you receive out of network are not covered.Therefore, we decided that the Plan does not have to reimburse you forthe comprehensive oral evaluation (D0150), the panoramic x-ray (D0330), the initial periapical x-ray (D0220), the 3 additional periapical x-rays (D0230), and the surgical extraction (D7140 x 8) provided from July 9, 2019 to September 17, 2019 by the out of network provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 20, 2019 to August 29, 2019 by an out of network (OON) provider.You asked the Plan to pay for home health care. You say that you have tried multiple times to become contracted with the Plan and are requesting payment of the claim.The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and prior authorization was not obtained.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 the medical services provided on August 20, 2019 to August 29, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on October 2, 2019.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 did not pre-approve the servicesat issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on October 2, 2019.