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

We decided that the Plan does not have to waive the copayment foran inpatient mental health stay provided from July 26, 2019 to July 29, 2019.You asked the Plan to waive the copayment foran inpatient mental health stay. You say that you did not authorize the stay and shouldnot be responsible for the bill.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $225 copayment per day for days 1-6 for inpatient mental health care. You had an inpatient mental health stay from July 26, 2019 to July 29, 2019. Therefore, you are responsible to pay a $225 copayment per day for days 1-3 (July 26, 2019 to July 28, 2019). $225 (copayment) x 3 (inpatient days) = $675.00.You have been asked to pay the total copayment amount of $675.00 for an inpatient mental health stay. An inpatient mental health stay falls within the inpatient mental health care 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 contractualobligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment foran inpatient mental health stay provided from July 26, 2019 to July 29, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Uribel capsules.
You asked the Plan to pre-approve Uribel capsules. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee has a medical only policy which does not include Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been met.
The Plan follows 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 Uribel capsules. Benefits for Uribel capsules 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve gingival irrigation (D4921) for all 4 quadrants, core
build up (D2950) for tooth # 9, and a crown (D2740) for tooth # 9.
You asked the Plan to pre-approve gingival irrigation for all 4 quadrants, core build up, and a crown for tooth #
9. The Plan denied your request. The Plan says the gingival irrigation, core build up, and crown are not listed as
covered services.
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 dental services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve
gingival irrigation (D4921) for all 4 quadrants, core build up (D2950) for tooth # 9, and a crown (D2740) for
tooth # 9.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Low Dose Computed Tomography (LDCT) Lung Cancer Screening (G0297).
You asked the Plan to pre-approve the LDCT screening. You say that the LDCT screening is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
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 LDCT screening. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found documentation notes the enrollee, who is 66 years old, has not smoked cigarettes since high school. The criteria are not met. 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 LDCT screening have not been met. Therefore, we decided that the Plan does not have to pre-approve a Low Dose Computed Tomography (LDCT) Lung Cancer Screening (G0297).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forlumbar-sacral orthosis (L0650) provided on June 14, 2019.You asked the Plan to waive the coinsurance for the orthosis. You say that you were not told that you would have a cost-share for the DME and feel you should not be held liable.The Plan denied your request. The Plan says the claim was processed accordingly with your 2019EOC 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 the orthosis on June 14, 2019. You are asked to pay 20% coinsurance for the DME. 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 forlumbar-sacral orthosis (L0650) provided on June 14, 2019
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided on May 6, 2019 by the out of network
provider.
You asked the Plan to pay for genetic testing. You say that the patient had never been informed of where her
analysis will be sent to and therefore can't be held responsible for our charges. The Plan denied your request.
The Plan says no prior authorization was obtained. The Plan says that the referring provider is an out-of-network provider.
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 genetic testing provided on May 6, 2019 by the out of
network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and sleeves for the enrollee.
You asked the Plan to pre-approve a pneumatic compression device and sleeves. You say that the enrollee has undergone a successful trial of the Flexitouch demonstrating positive clinical response with tolerance of treatment and ability to don/doff the garments. The Plan denied your request. The Plan says that the enrollee must complete a four week trial of E0650 or E0651 to qualify for the E0652.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and sleeves for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forCPAP device provided From June 18, 2019 through September 18, 2019.You asked the Plan to waive the copayment forthe CPAP device. You say that you are appealing your cost-share responsibility for the services you received.The Plandenied 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 the CPAP device provided from June 18, 2019 through September 18, 2019. You are asked to pay 20% coinsurance each of the four (4) months for the DME. 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 forCPAP device provided From June 18, 2019 through September 18, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional outpatient mental health services.You asked the Plan to pre-approve the mental health services. You say that the services are medically necessary.The Plan denied your request. The Plan says coverage criteria has not been met.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 mental health services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found it does not appear that this patient requires additional treatment sessions as utilizing the CMS criteria for coverage he does not appear to show appropriate illness criteria for continued therapy as a psychiatrist and two psychologists have said that this patient has maximized his benefit from therapy.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 mental health services have not been met.Therefore, we decided that the Plan does not have to pre-approve additional outpatient mental health services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aviva blood glucose reagent strips.
You asked the Plan to pre-approve the Aviva Strips. You say that you are comfortable with your current testing
strips and are concerned about switching to a new manufacturer. The Plan denied your request. The Plan says
the Aviva Strips are not a preferred product and not a covered benefit.
The Plan follows Medicare rules. Medicare rules say that MA plans may specify brands and manufacturers as
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred
brands and manufacturers.
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 Aviva Strips. Our reviewer says that
the Aviva strips are not medically reasonable and necessary. Our physician reviewer found the documentation
does not indicate a specific reason as to why you are incapable of using the Plan's preferred brand or why the
preferred brand is something you cannot use appropriately.
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 Aviva Strips have not been met. Therefore, we decided that the Plan does
not have to pre-approve Aviva blood glucose reagent strips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Group 2 standard power wheelchair and accessories.You asked the Plan to pre-approvea Group 2 standard power wheelchair and accessories. You say thatyour current power wheelchair is dangerous and you need to be able to get around outside your home, in the 
community.The Plan denied your request. The Plan says prior physical therapy evaluations have shown adequate upper body strength to use a manual wheelchair and Medicare does not cover power wheelchairs for use only outside the home.The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating therequested PMD. The file does not showthat you have a mobility deficit that impairs your participation in MRADLsor your condition cannotbe improved by a walker, cane or manual wheelchair. Your provider states that you walk on a limited basis in your place of residence. There is no current physical therapy assessment. There is no estimate of repairs on your current power wheelchair. You are requesting a new power wheelchair for community use. This means that Medicare rules for coverage of a PMDhave not been met.Therefore, we decided that the Plan does not have to pre-approvea Group 2 standard power wheelchair and accessories.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve non-covered item, orthopedic pillow tempur pedic (A9270).
You asked the Plan to pre-approve the tempur pedic pillow. You say that you are appealing because your physician had certified that you needed it. The Plan denied your request. The Plan says tempur pedic are commercial products sold by commercial non DME companies. This item is not covered.
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 pre-approve non-covered item, orthopedic pillow tempur pedic (A9270).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for hearing aids provided on August 13, 2019.
You asked the Plan to reimburse you for the hearing aids. The Plan denied your request. The Plan says you
must receive care from in-network providers with the exception of emergency or urgent care, dialysis while
temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which
requires prior authorization from the plan.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. 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.
We looked at the file and the Plan's rules. The requested provider in this case is not a network provider with the
Plan. The Plan did not pre-approve the hearing aids. We found no exception that would require the Plan to
reimburse you for the hearing aids. Therefore, we decided that the Plan does not have to reimburse you for
hearing aids provided on August 13, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean outpatient office visit.You asked the Plan to pre-approvethe officevisit. You say that this service is a medical need and not cosmetic. You also say that you cannot locate any contracted physicians that will help you and this provider is willing to remove bone from your hip to replace it into your chin.The Plan denied your request. The Plan says this provider is non-contracted with your plan. The Plan also says that you are required to use the Plan's network providers to care for and treat your health issues.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 pre-approved care.The requested provider in this case isnot 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-approvean outpatient office visit.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on April 29, 2019 to June 20, 2019 by out of network provider.You asked the Plan to pay forthese services. You say that the provider told you on October 9, 2019 that they were not in-network.The Plan denied your request. The Plan says the services were rendered by a non-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 April 29, 2019 to June 20, 2019 by out of network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for3D rendering with interpretation and reporting of another imaging service (76376) provided on 3D rendering.You asked the Plan to pay for3D rendering. You say that this should be paid.The Plan denied your request. The Plan says this service is not separately payable.The Plan follows Medicare rules. Medicare rules say that 3D rendering with interpretation and reporting requiring and not requiring image post processing will not be considered medically reasonable and necessary if equivalent information obtained from the test has already been provided by another procedure  or if it could be provided by astandard CT scan without reconstruction. 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 3D rendering. Our reviewer says that 3D rendering was not medically necessary. Our physician reviewer found the documentation does not support that the additional 3D image was necessary for a complete depiction of an abnormality from the 2D study or for surgical planning.  The available documentation also does not support that information was obtained from the 3D imaging that could not have been obtained from 2D imaging.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 3D rendering have not been met.Therefore, we decided that the Plan does not have to pay for3D rendering with interpretation and reporting of another imaging service (76376) provided on 3D rendering.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the medical eye exam provided on August 28, 2019.You asked the Plan to waive the copayment for the medical eye exam. You say that you had a routine vision exam and the doctor said your vision is good but early start of cataracts. You say you should not be responsible for the 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 $35 copayment for Medicare-covered eye exams to diagnose and treat diseases and conditions of the eye. You have been asked to pay a $35 copayment for the medical eye exam. The medical eye exam falls within the "Vision care" benefit category. The record shows you were diagnosed with age-related cataracts which makes the eye exam medical in nature.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 medical eye exam provided on August 28, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvetotal electric hospital bed (E0265).You asked the Plan to pre-approvethe total electric hospital bed. You say that you would like to appeal the denial of the automatic hospital bed.The Plan denied your request. The Plan says this item is not covered under Medicare.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 in this case, neither the Plan nor Medicare offers coverage for this item.Therefore, we decided that the Plan does not have to pre-approvetotal electric hospital bed (E0265).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approve acute inpatient rehabilitation facility (IRF) admission and services.You asked the Planto pre-approveIRF care. You say that you believe that IRF care is medically necessary.The Plandenied your request. The Plansaysthe criteria for coverage of IRF care are not 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 the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require, or to be able to perform, fifteen hours per week of rehabilitative services with regular physician evaluation. The enrollee's care needs can be met at a lower level of care (ex. SNF/SAR).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 Plandoes not haveto pre-approveacute inpatient rehabilitation facility (IRF) admission and services.