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

We decided that the Plan does not have to pre-approve total electric hospital bed with special features (E0265).
You asked the Plan to pre-approve the hospital bed. You say that the enrollee has MS and is unable to get out of bed. You need the electric bed to be able to raise and lower her without hurting yourselves. This will benefit her as well as her caregivers. The Plan denied your request. The Plan says this item is not covered by 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-approve total electric hospital bed with special features (E0265)
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copay forthe urgent care services you received on November 10, 2019.You asked the Plan to waive the copay forthe services provided. You say that the services relate to your first visit.The Plan denied your request. The Plan says the claim was processed based on your plan 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). Your contract with the Plan clearly says that you must pay a $55 copay for each Medicare-covered urgent care provider visit for urgently needed services. You have been asked to pay a $55 copay for the services provided. The services fall within the urgently needed services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copay forthe urgent care services you received on November 10, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a positioning cushion.
You asked the Plan to pre-approve a positioning cushion. You say that the enrollee needs a positioning cushion to help avoid bed sores. The Plan denied your request. The Plan says a positioning cushion is considered by Medicare to be a comfort or convenience item and therefore 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 a positioning cushion.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that chronic right foot pain with numbness. 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 pre-approve foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Flexitouch pneumaticcompression device (E0652).You asked the Plan to pre-approvea Flexitouch. You say that this is medically necessary.The Plan denied your request. The Plan says that the enrollee did not fail a 4 week trial of the basic pump.The Plan followsMedicare 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 orE0651. 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-approvea Flexitouch pneumatic compression device (E0652).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a deluxe upgraded heavy duty rollator.
You asked the Plan to pre-approve a deluxe upgraded heavy duty rollator with upgraded seat, basket and closure lock. You say that you feel secure using the sturdier product. The Plan denied your request. The Plan says coverage cannot be provided for a deluxe upgraded model but can be approved for a standard heavy duty walker.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a deluxe upgraded heavy duty rollator have not been met. Therefore, we decided that the Plan does not have to pre-approve a deluxe upgraded heavy duty rollator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the prosthetic services to be provided by an out of network provider 
You asked the Plan to pre-approve the prosthetic services. You say that you have done months' worth of follow up and clinical care and changing to another provider would take 4-8 weeks for the enrollee to receive the prosthesis. The Plan denied your request. The Plan says the services requested are available in-network and there is no justification to use out-of-network benefits.
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 prosthetic services to be provided by an out of network provider
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to reduce the coinsurance for the radiation therapy provided from
August 6, 2019 to September 30, 2019.
You asked the Plan to reduce the coinsurance for the radiation therapy. You say that you disagree with the high
coinsurance amount. 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 20%
coinsurance for each in-network visit for therapeutic radiology services.
You have been asked to pay a total of $4,072.03 for the radiation therapy. The radiation therapy falls within the
"Outpatient diagnostic tests and therapeutic services and supplies" benefit category. See chart below.
Date of Service Service Allowed Amount Coinsurance Member Liability
August 6, 2019 Radiation treatment
aid
$170.37 20% $34.07
August 26, 2019 Radiotherapy dose
plan
$122.67 20% $24.53
August 26, 2019 Design MLC
device
$2,896.19 20% $579.24
August 26, 2019 Radiation therapy
dose plan
$538.35 20% $107.67
September 3, 2019 IMRT $763.23 20% $152.65
Date of Service
Service
Allowed Amount
Coinsurance
Member Liability
September 4, 2019
IMRT
$763.23
20%
$152.65
September 5, 2019
IMRT
$763.23
20%
$152.65
September 6, 2019
IMRT
$808.04
20%
$161.61
September 9, 2019
IMRT
$808.04
20%
$161.61
September 10, 2019
Radiation physics consult
$151.51
20%
$30.30
September 10, 2019
IMRT
$808.04
20%
$161.61
September 112019
IMRT
$808.04
20%
$161.61
September12, 2019
IMRT
$808.04
20%
$161.61
September 13, 2019
IMRT
$808.04
20%
$161.61
September 16, 2019
IMRT
$808.04
20%
$161.61
September 17, 2019
Radiation physics consult
$151.51
20%
$30.30
September 17, 2019
IMRT
$808.04
20%
$161.61
September 18, 2019
IMRT
$808.04
20%
$161.61
September 19, 2019
IMRT
$808.04
20%
$161.61
September 20, 2019
IMRT
$808.04
20%
$161.61
September 23, 2019
IMRT
$808.04
20%
$161.61
September 24, 2019
Radiation physics consult
$151.51
20%
$30.30
September 24, 2019
IMRT
$808.04
20%
$161.61
September 25, 2019
IMRT
$808.04
20%
$161.61
September 26, 2019
IMRT
$808.04
20%
$161.61
September 27, 2019
IMRT
$808.04
20%
$161.61
September 30, 2019
Radiation physics consult
$151.51
20%
$30.30
September 30, 2019
IMRT
$808.04
20%
$161.61
Total
$4,072.03
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 reduce the coinsurance for the radiation therapy provided from August 6, 2019 to September 30, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve crowns for tooth #'s 6 & 12 and post and cores in addition to crowns for tooth #'s 6 & 12.
You asked the Plan to pre-approve the crowns and post and cores. You say that you need these dental procedures because you have a lot of discomfort. The Plan denied your request. The Plan says these services are not covered benefits under your 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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea partial ostectomy or sequestrectomy for removal of non-vital bone (D7550).You asked the Plan to pre-approvethe partial ostectomy or sequestrectomy for removal of non-vital bone. You say that your dentist was supposed to do the whole thing at one time and you were supposed to get dentures. You say it should have been done in the first procedure. You also say that the doctor should be responsible for it since he was the one who chose to do thesurgery at 2 separate times.The Plan denied your request. The Plan says the partial ostectomy or sequestrectomy for removal of non-vital bone is not listed as a covered 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.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested dental service is not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvea partial ostectomy or sequestrectomy for removal of non-vital bone (D7550).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the ankle foot orthoses and heel cup
You asked the Plan to pay for the ankle foot orthoses (L1971) and heel cups (L3170). You say that the orthoses were 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 for the ankle foot orthoses and heel cups on June 4, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecore build up (D2950) for teeth # 20 and 21.You asked the Plan to pre-approvethe core build up. You say that the existing crowns on teeth # 20 and 21 have open margins, are splinted and the enrollee is unable to floss. You say the gingival tissue is very inflamed and there is decay on the mesial surface of tooth # 20 and on distal surface of tooth # 21. You also say that the existing crowns are over 10 years old and need to be replaced with a new crown to restore the function and health of the enrollee.The Plan denied your request. The Plan says core build up is not listed as a covered 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.Though the Plan offers a dental benefit in excess of Medicare coverage, core build up is not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvecore build up (D2950) for teeth # 20 and 21.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a seat lift chair.
You asked the Plan to pre-approve the seat lift mechanism of a seat lift chair. You say that a seat lift chair will make life easier for you to get around. The Plan denied your request. The Plan says the records do not show you meet the requirements.
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed above are met. Medicare does not cover the upholstered portion of a seat lift chair. We looked at the file and Medicare rules. The record shows this is not part of your practitioner's course of treatment, and you are not unable to stand from a chair. Based on this information, we decided that Medicare rules for coverage of the seat lift mechanism of a seat lift chair have not been met. Therefore, we decided that the Plan does not have to pre-approve a seat lift chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveattendant controller (E2331) and Accu-Trac Motor Technology, Wheelchair component or accessory (K0108).You asked the Plan to pre-approvethe attendant controls and Accu-trac Motor Technology. You say that the Accu-Trac accessory is medically necessary for the enrollee due to their diagnosis of multiple sclerosis with ambulatory dysfunction.The Plan denied your request. The Plan says the plan had approved an expandable controller (E2377) , therefore the attendant controller (E2331)  is non-covered per Local Coverage Article guidelines. The Accu-Trac technology is a convenience item and not needed for in-home use.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Based on this information, we decided that Medicare rules for coverage of the attendant controls and Accu-Trac Motor Technology have not been met.Therefore, we decided that the Plan does not have to pre-approveattendant controller (E2331) and Accu-Trac Motor Technology, Wheelchair component or accessory (K0108).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forhome health aide services provided from May 21, 2017 to June 13, 2017.You asked the Plan to pay forhome health aide services. You say that you are requesting that the Plan make a determination of these claims.The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is not a Medicare participating provider and is therefore not covered by the Plan.ThePlan must follow Medicare rules. Medicare rules say that to receive payment for Medicare-covered services, a provider must be enrolled in the Medicare program. The Plan contract says that a doctor must certify that the enrollee needs home health services,and order home health services to be provided by a home health agency.We looked at the file and Medicare rules. This provider is not eligible to participate in Medicare and is not payable by the Plan. Furthermore, the documentation submitted does not show that a doctor certified these home health services and ordered them from this home health agency. Based on this information, we decided that Medicare rules for coverage of home health aide services have not been met.Therefore, we decided that the Plan does not have to pay forhome health aide services provided from May 21, 2017 to June 13, 2017.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services
You asked the Plan to pre-approve the physician's services. You say that you have been a long standing patient of this physician. You say in 2016 he performed your bladder surgery to remove malignant tumors and he continues to monitor your condition. You say later you were diagnosed with prostate cancer and he continues to monitor this condition. The Plan denied your request. The Plan says the standard of care for the requested service is available within the Plan's network.
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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physician's services
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvephysician's services to be provided by "the doctor".You asked the Plan to pre-approve the physician's services. You say that this physician is close to your home and you like him. You say this physician treats your heart condition and prescribes your medication. 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 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physician's services to be provided by "the doctor".
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services
You asked the Plan to pre-approve the physician's services. You say that the enrollee has a foot condition that needs to be treated very soon. 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 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physician's services
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on May 6, 2019.
You asked the Plan to pay for drug tests. You say that you have submitted a valid physician laboratory requisition form. The Plan denied your request. The Plan says the denial of payment for these services is correct, because the documentation submitted does not include a valid physician order, laboratory requisition, or medical records stating exactly which tests were to be performed.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a valid physician order or clear intent to order the specific lab services billed on this claim. Based on this information, we decided that Medicare rules for coverage of drug tests have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided on May 6, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on October 24, 2019.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 service at 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 the laboratory services provided on October 24, 2019.