Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on December 29, 2019. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you never requested a private room. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance).  
 
Review of the file show that you received inpatient hospital care provided on December 29, 2019. Your EOC states, enrollees must pay a $350 copayment for each Medicare-covered hospital stay. Therefore, you are asked to pay a $350 copayment for the inpatient hospital care, not for a private room. 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 inpatient hospital care provided on December 29, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient surgery services rendered on
November 25, 2019.
You asked the Plan to waive the copayment for these services. You say that you disagree with the charges. The
Plan denied your request. The Plan says the copayment was 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 a $250
copayment for each out-of-network outpatient hospital visit.
Review of the file shows that you received outpatient surgical services from an out-of-network provider on
November 25, 2019. Per the contract with the Plan, there is a $250 copayment for each out-of-network
outpatient hospital visit. This cost sharing is a contractual obligation you agreed to pay when you enrolled in
the Plan. However, the Medicare allowed amount for these services was $181.21. Given that the allowed
amount was less than the $250 copayment, you have been asked to pay $181.21 for these services.
Therefore, we decided that the Plan does not have to waive the copayment for the outpatient surgery services
rendered on November 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a TributeNight facial garment.
You asked the Plan to pre-approve these services. You say that your neck is swollen and it causes great pain and problems with speech. The Plan denied your request. The Plan says the item is not covered.
The Plan must follow Medicare rules. Medicare rules say that compression stockings are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound. The TributeNight facial garment is a type of compression stocking. The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you do not have a medical condition for which compression stockings can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve a TributeNight facial garment.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lantus Solostar.
You asked the Plan to pre-approve these 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-approve Lantus Solostar.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265).
You asked the Plan to pre-approve a total electric hospital bed. You say that a total electric hospital bed is medically necessary for the enrollee. The Plan denied your request. The Plan says a total electric hospital bed is not a covered benefit under the enrollee's contractual policy.
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate for the enrollee in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital (E0265).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xiidra eye drops.
You asked the Plan to pre-approve Xiidra eye drops. You say that this is necessary because the enrollee has dry eyes and artificial tears don't help. The Plan denied your request. The Plan says coverage of this medication is the responsibility of Medicare Part D.
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 Xiidra eye drops.
Benefits for Xiidra eye drops 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6533.
You asked the Plan to pre-approve the compression stockings. You say that the enrollee has residual blisters on
lower legs. The Plan denied your request. The Plan says the stockings are examples of wound care items which
are non-covered under the surgical dressing benefit because they do not meet the statutory definition of a
dressing.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533 are
non-covered because they do not meet the statutory definition of a surgical dressing.
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression
stockings identified with code A6533.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6530. 
 
You asked the Plan to pre-approve the compression stockings. You say that you have lymphedema of the lower extremities. The Plan denied your request. The Plan says the compression stockings are not covered. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve crowns (D2750) for tooth #'s 8 & 9. 
 
You asked the Plan to pre-approve the crowns. You say that the enrollee needs crowns on tooth #'s 8 & 9 because both of these teeth have broken lingual incisal surfaces. You also say that fillings do not work in these teeth, and both teeth need crowns in order to avoid complete fracture. The Plan denied your request. The Plan says the medical necessity criteria for crowns on teeth #8 and #9 is not met. The Plan also says that the x-rays do not show that these teeth are badly broken or rotten. 
 
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. The Plan covers the crowns when the services are medically necessary and reasonable.  
 
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 crowns. Our reviewer says that the service is not medically necessary. Our physician reviewer found due to the lack if significant coronal breakdown, the criteria for coverage for crown restorations (D2750) for teeth #'s 8 and 9 have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the crowns have not been met. Therefore, we decided that the Plan does not have to pre-approve crowns (D2750) for tooth #'s 8 & 9.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove intermittent limb compression device. You asked the Plan to preapprove intermittent limb compression device. You say that the enrollee requires the device. The Plan denied your request. The Plan says pneumatic compression devices are not covered by Medicare for restless leg syndrome or pain. The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically necessary for the treatment of lymphedema and/or for the treatment of chronic venous insufficiency with venous stasis ulcers. The file does not show that the enrollee has lymphedema and/or chronic venous insufficiency with venous stasis ulcers. Therefore, we decided that the Plan does not have to preapprove intermittent limb compression device.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy visits.
You asked the Plan to pre-approve the additional physical therapy visits. You say that you had three major surgeries within nine months you and cannot walk and you need additional physical therapy to get out of SNF care. The Plan denied your request. The Plan says additional physical therapy is not medically necessary.
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 the additional physical therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that additional therapy beyond what was authorized by the health Plan is not generally accepted as specific and effective therapy for your condition. You were authorized for prior therapy but the documentation does not reveal evidence of objective outcomes from the prior authorized therapy. It appears that a most recent telemedicine visit indicates that you can walk with a therapist but without additional documentation from the initial authorized therapy visit it is not clear that you require the unique skills of a professional therapist to safely and effectively provide treatment or that services need to safely and effectively be performed only by a therapist, or under the supervision of a therapist. The requested services are not part of a maintenance program and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration.
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 additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy visits.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the SNF admission.
You asked the Plan to pre-approve the SNF admission. The Plan denied your request. The Plan says the criteria is not met. The Plan also says that you are at your baseline and are unlikely to benefit from therapy.
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 pre-approve the SNF admission. Our reviewer says that you do not meet the Medicare criteria for SNF care. Our physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do 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 SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve the SNF admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider. 
 
You asked the Plan to pre-approve the home ventilator (E0466, E0483 and E1390). You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says there are innetwork durable medical equipment providers who can provide the necessary supplies. 
 
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 the medical services to be provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prednisone for the enrollee. 
 
You asked the Plan to pre-approve Prednisone. You say that Prednisone is medically necessary. The Plan denied your request. The Plan says Prednisone is not covered under Medicare 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 Prednisone for the enrollee.  
 
Benefits for Prednisone 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care to be
provided beyond July 29, 2020.
You asked the Plan to pre-approve the continued SNF care. You say that you continue to require 24-hour
nursing care and would benefit from ongoing daily therapy so you can continue to gain strength. The Plan
denied your request. The Plan says your needs are mainly custodial and can be met with less than daily skilled
services.
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 pre-approve the continued SNF care. Our reviewer
says that daily skilled services are not necessary. Our physician reviewer found the beneficiary is a 64 year old
male with diabetes, schizophrenia, acute kidney injury, atrial fibrillation and diabetic ketoacidosis admitted to
the SNF on July 17, 2020. From a nursing perspective, the beneficiary received oral medications. The
beneficiary had stable vital signs. He completed a course of antibiotics. He had routine Foley catheter care.
Regarding rehabilitation services, the beneficiary received PT and OT in the SNF. By the dates in question, the
beneficiary was independent with bed mobility and transfers and at a stand by assist level with gait to 100 feet.
The beneficiary was independent with ADLs. He could negotiate stairs with contact guard assist.
There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs.
This beneficiary no longer meets severity of illness or intensity of service criteria for an inpatient basis in a
skilled nursing facility 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 continued SNF care have not been met. Therefore, we decided that the Plan
does not have to pre-approve continued skilled nursing facility (SNF) care to be provided beyond July 29,
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home ventilator, any type, used with non-invasive
interface, (e.g., mask, chest shell) (E0466), for the enrollee.
You asked the Plan to pre-approve the DME. You say that the durable medical equipment is medically
necessary. The Plan denied your request. The Plan says the durable medical equipment is not medically
necessary.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory
failure due to COPD.
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 DME. Our physician reviewer
found coverage criteria for a home ventilator are not met. This patient has chronic obstructive pulmonary
disease (COPD) and is on oxygen. There are no pulmonary function data to confirm the diagnosis. An arterial
blood gas shows mild elevation of the partial pressure of carbon dioxide (pCO2) to 48, but it is not clear
whether this was done during medical stability. The patient may qualify for Bilevel Positive Airway Pressure
(BiPAP) support at night. But Medicare does not cover a home ventilator when used as BiPAP. Certain BiPAP
devices are capable of providing the AVAPS-AE mode of support that has been ordered. Furthermore, usage of
the ventilator has not met the minimum criteria of at least 4 hrs/night for at least 70% of nights. A home
ventilator 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 the DME have not been met. Therefore, we decided that the Plan does not have
to pre-approve home ventilator, any type, used with non-invasive interface, (e.g., mask, chest shell) (E0466),
for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Entresto for the enrollee.
You asked the Plan to pre-approve Entresto. You say that Entresto is medically necessary for the enrollee. The Plan denied your request. The Plan says this drug is not covered 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-approve Entresto for the enrollee.
Benefits for Entresto 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network home health provider. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are available from network providers. 
 
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. The Plan confirmed that the network provider has staff that speaks Spanish. 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 a referral to an out-of-network home health provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider.
You asked the Plan to pre-approve these services. You say that there are a limited number of cardiologists that can help the enrollee's condition. The Plan denied your request. The Plan says the services are available from network providers.
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. The Plan confirmed that the network providers are able to treat the enrollee's condition. 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 a referral to an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for fluoride treatment (D1206) provided on January 30, 2020.
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says the service is not a covered benefit under the plan.
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. This service is not listed in your EOC as a covered benefit; therefore, it is not covered. Therefore, we decided that the Plan does not have to pay for fluoride treatment (D1206) provided on January 30, 2020.