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

We decided that the Plan does not have to pay for ankle foot orthosis (L1940) provided to the enrollee on February 8, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the claim for services were filed more than 1 year after the date of service.
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 orthosis was not filed until February 18, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. This decision is only regarding whether the Plan is required to make payment for this item, and does not make any determination about whether you are financially liable for the brace as the provider is required to file the claim within the time frame in order to receive payment. Therefore, we decided that the Plan does not have to pay for ankle foot orthosis (L1940) provided to the enrollee on February 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea portable ventilator.You asked the Plan to pre-approvea portable ventilator. You say that this portable ventilator provides positive pressure ventilatory support and is mobile.The Plan denied your request. The Plan says the enrollee does not meet criteria for medical necessity of the requested service.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 a portable ventilator. Our reviewer says that a ventilator is not medically necessary. Our physician reviewer found coverage criteria for a home ventilator are not met. This enrollee does have severe COPD, but there is no documentation of increased pCO2. There is also no evidence that BiPAP has been tried. Medicare does not cover a ventilator when used as a BiPAP device.In this case, the requested devicehas been ordered. This device is not actually a ventilator, and has not been clearly demonstrated to be effective in the treatment of severe COPD. A home ventilator is considered not medically necessary, and the denial is upheld.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a portable ventilator have not been met.Therefore, we decided that the Plan does not have to pre-approvea portable ventilator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. 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 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 records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a SNF. In this case, you are mostly moderate assist for functional transfers and up to maximum assist for lower body activities of daily living (ADL's) and a less intensive, longer duration of therapy will allow for measurable gains to be attained within a reasonable, and predicted period. An IRF intensity is not warranted. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the deluxe frames and lenses purchased March 13, 2020.
You asked the Plan to pay for the vision services. You say that you understand the standard charges. You would like the standard payment made as you have paid the remainder. The Plan denied your request. The Plan says deluxe features are not covered under the plan benefits.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when the plan covers for one pair of Medicare covered standard glasses or contacts after each cataract surgery. We looked at the file and the Plan's rules. The plan covers for one pair of Medicare covered standard glasses or contacts after each cataract surgery. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pay for the deluxe frames and lenses purchased March 13, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forDecisionDx-Melanoma testing provided on November 6, 2019.You asked the Plan to pay forgenetic test. You say that you are appealing with medical records.The Plan denied your request. The Plan says the denial of payment for this service is correct, because the enrollee's melanoma was classified as T4A with Breslow thickness at least 6mm and involvement of the lateral and deep margins, thus is does not meet Medicare criteria for coverage.The Plan follows Medicare rules. Medicare rules say that DecisionDx-Melanoma testing is only covered for the specific clinical indications listed 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 pay for genetic test. Our reviewer says that this testing does not meet the Medicare criteria for coverage. Our physician reviewer found the difficulty in embracing gene expression profiling as an independent predictor of outcome is illustrated by the inconsistency of results across studies aimed at defining the most predictive gene sets for melanoma. The lack of overlap in gene signatures identified as prognostic for melanoma is likely due to substantial differences in study design and methodology. Furthermore, a high risk DecisionDx-Melanoma result does not translate into a therapeutic intervention as adjuvant immunotherapy is reserved for node positive Stage III disease. The record defines follow-up for Stage IA-IIA and IIB-IB respectively. Follow-up is not dictated by DecisionDx-Melanoma risk profile. Therefore, this use of DecisionDx-Melanoma testing is experimental/investigational as to treatment and surveillance.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of genetic test have not been met. Therefore, we decided that the Plan does not have to pay forDecisionDx-Melanoma testing provided on November 6, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for Extraction, erupted tooth or exposed root (D7140) provided November 1, 2019.
You asked the Plan to pay for the dental services. You say that this was an emergency. A filling fell off and you had a big hole in your tooth and the pain was horrible. This was the only dentists willing to take you right in. None of the network providers would help. The Plan denied your request. The Plan says enrollee's must receive their dental services from an in-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. The health plan contract says that you must visit a participating dental network provider to receive dental benefits. 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 Extraction, erupted tooth or exposed root (D7140) provided November 1, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Purewick female external catheter system to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the female external catheter. You say that this is a medical necessity and you disagree with the denial. You spoke with Medicare and they told you this was covered. 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 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 Purewick female external catheter system to be provided by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic mammogram provided on January 10, 2020.
You asked the Plan to waive the copayment for the diagnostic mammogram. You say that a mammogram should be a $0 copayment. The Plan denied your request. The Plan says the copayment 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 $10 copayment for most x-rays and ultrasounds. You have been asked to pay a $10 copayment for the diagnostic mammogram. The diagnostic mammogram falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The records show that a diagnostic mammogram was performed due to a personal history of breast cancer. 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 the diagnostic mammogram provided on January 10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. You say that the enrollee will benefit from inpatient physical therapy for strengthening, conditioning, balance, and gait training.The Plan denied your request. The Plan says the enrollee does not have complex medical conditions which require physician supervision, or a multidisciplinary team for care.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 tocarefully 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 the enrollee was admitted to the acute hospital after a fall at home, and suffered a fractured left hip. He is at minimal assist for bed mobility and ambulating using a rolling walker. He was at contact guard assist for transitional movements and static standing. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee'smedical status does not currently require intensive physician and nursing oversight only in an IRF.Hehad no significant post-operativeissues. The enrolleemay benefit from multiple therapies,such as physical and occupational therapy,but the documentation does not support that he requires or can tolerate an intensive rehabilitation therapy program provided 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the ophthalmology services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve OON ophthalmology services. You say that the enrollee should get a second opinion and you were recommended an OON provider. The Plan denied your request. The Plan says there are several providers available in-network that can provide the requested 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 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 ophthalmology services to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea shower chair.You asked the Plan to pre-approvea shower chair. You say that you want to appeal the Plan's denial of the requested bath chair. You say that you have diabetes and your legs shake a lot due to your medical issues. You stated that you have fallen on three separate occasions and have hurt your back. You say that you would feel safer with the bath chair.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of thisitem.Therefore, we decided that the Plan does not have to pre-approvea shower chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea shower chair.You asked the Plan to pre-approvea shower chair. You say that you need the requested shower chair because you have not been able to shower for several weeks. You say that you are developing a soreand you asked the Plan to reconsider their denial of the requested shower chair.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.Therefore, we decided that the Plan does not have to pre-approvea shower chair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for intraoral-periapical first radiographic image (D0220) and the intraoral-periapical each additional radiographic image (D0230 x 2) provided on February 27, 2020.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit under your contractual policy.
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 services provided are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for intraoral-periapical first radiographic image (D0220) and the intraoral-periapical each additional radiographic image (D0230 x 2) provided on February 27, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services for the enrollee.You asked the Plan to pre-approvethe LTACH services. You say that this is medically necessary for the enrollee.The Plan denied your request. The Plan says that the acute care hospital was the appropriate level of care for the member's needs at thistime.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. The enrollee is currently at the appropriate level of care and still has several pressing problems that make her too high of a level at this time for LTACH placement. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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 for the enrollee.
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 on the date of service you slipped while taking a shower and you hit your head. You say that your family was not sure of the full extent of your injuries so they called 911 for help. When the responders arrived they treated your wounds and checked your vitals. You stated that they recommended that you go to the hospital to be examined and said that they could take you or you could go with your family. You say that at that point you were movable and in a stable condition. You asked the Plan to reconsider paying for the charges because you say that the services were medically necessary for you. 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 December 24, 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services.You asked the Plan to pay forthe ambulance services. You say that you accidentally knocked a knife off of a cutting board and it fell onto your foot. You say that your son helped you to a chair and immediately called for paramedics due to the amount of blood he had witnessed. You stated that when the paramedics arrived they removed the dressings on your foot and saw that the bleeding had stopped. They checked your vital signs and recommended that you go to the emergency room for further evaluation. You say that they gave you the choice of being transported by your family or by ambulance and you decided to have your family take you. You stated that at the emergency room you received stitches and a necessary tetanus shot. You asked the Plan to reconsider their denial of the ambulance services.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 November 28, 2019. Theambulance 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 forthe ambulance services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia for the enrollee.
You asked the Plan to pre-approve Prolia. You say that the enrollee is very osteoporotic. The Plan denied your request. The Plan says that they didn't receive criteria addressing step therapy criteria.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Prolia. Our reviewer says that Prolia is not medically reasonable and necessary for the enrollee in this case. The enrollee has not tried and failed zoledronic acid and does not have a history of osteoporotic fracture. The documentation does not support that zoledronic acid would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Prolia.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia for the enrollee.