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

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve inpatient rehabilitation facility care. You say that an inpatient rehabilitation facility admission is medically necessary. The Plan denied your request. The Plan says that you do not meet criteria for coverage of an inpatient rehabilitation facility admission.
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 inpatient rehabilitation facility care. Our reviewer says that the requested inpatient rehabilitation facility care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that your medical conditions appear stable. You do not have any unaddressed medical issues and do not require medical oversight of your condition at an acute hospital level of care. You do require physical therapy for mobility and occupational therapy for activities of daily living. An intensive rehabilitation therapy program is not required. Additionally, you would not be expected to be able to fully participate in or benefit from the required intensity of an acute rehabilitation therapy program. An intensive rehabilitation therapy program would not significantly impact your condition differently compared with therapy provided at a less intense level. Your care can be appropriately provided at a skilled nursing facility level. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient rehabilitation facility care have not been met. Therefore, we decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Eversense implantable continuous glucose monitor for the enrollee.
You asked the Plan to pre-approve the requested services. You say that clinical trials show overall improvement in the hemoglobin a1c. The Plan denied your request. The Plan says the system is non-covered as it is considered not medically necessary. 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 the information provided, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve an Eversense implantable continuous glucose monitor for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a prostatectomy provided by the Hospital on November 4, 2019.You asked the Plan to waive the copayment fora prostatectomy. You say that you received services in an ambulatory surgical center, not an outpatient hospital facility, and disagree with the charges.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 $200 copayment for each outpatient hospital facility visit.You received a prostatectomy at an outpatient hospital facility on November 4, 2019. Therefore, you are responsible to pay the $200 copayment.  You have been asked to pay a $200 copayment for a prostatectomy. A prostatectomy falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. This means that you have been asked to pay the correct amount based on your contractwith 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 fora prostatectomy provided by the Hospital on November 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the routine foot care you received on December 4, 2019. 
 
You asked the Plan to pay for the foot care. You say that you thought it might have been a tumor. The Plan denied your request. The Plan says routine foot care is not covered. 
 
The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or feet or have fungal nails.  
 
The records do not show that any of these conditions are present. The services you are asking the Plan to pay for are routine foot care services. Based on this information, we decided that Medicare rules for coverage of the foot care have not been met. Therefore, we decided that the Plan does not have to pay for the routine foot care you received on December 4, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Spiriva Respimat 1.25 mcg inh (J3535). You asked the Plan to pre-approve Spiriva Respimat 1.25 mcg inh. You say that the medication is necessary. The Plan denied your request. The Plan says you have 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 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 Spiriva Respimat 1.25 mcg inh (J3535).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ambulatory short term glucose monitoring for the enrollee.You asked the Plan to pre-approve the services. You say that there is a significant discrepancy between the enrollee's blood sugars and the HbA1C.The Plan denied your request. The Plan says insulin is not required, and finger stick glucose monitoring is not performed at least four times daily.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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is noted to have type II diabetes, which is not treated with insulin. The enrollee tests her blood glucose once a day. The results of this daily blood glucose monitoring are not used to adjust insulin dosages multiple times a day. Therefore, the requested monitoring is not shown to be medically necessary or reasonable.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 services have not been met.Therefore, we decided that the Plan does not have to pre-approve ambulatory short term glucose monitoring for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown for tooth #30.
You asked the Plan to pre-approve the crown. The Plan denied your request. The Plan says this service exceeds the benefit allowance.
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, crowns are limited to once per tooth every 5 years. The record shows that you received a crown on tooth #30 on July 3, 2017 and your crowns benefit for tooth #30 is now exhausted. Therefore, we decided that the Plan does not have to pre-approve a crown for tooth #30.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health nurse visits, two times a day.
You asked the Plan to pre-approve the visits. You say that this is medically necessary. The Plan denied your request. The Plan says one skilled nursing visit per day would be adequate, if not more than the enrollee requires.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or 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 visits. Our reviewer says that the requested visits are not medically reasonable or necessary. Our physician reviewer found the records do not show that these visits are required to effectively provided treatment, care, and/or services which are medically necessary necessary. There is no detailed evaluation of your wounds, which indicate a level of severity and complexity that requires two times a day visits. 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 visits have not been met. Therefore, we decided that the Plan does not have to pre-approve home health nurse visits, two times a day.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forinpatient hospital services provided September 14 to September 19, 2019.You asked the Plan to waive the copayment forthe inpatient services. You say that the services were of poor quality and the copayment should be waived.The Plan denied yourrequest. The Plan says the correct copayment was applied.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 $372.00 copayment for each day for days 1-5 for Inpatient Hospital Care. You have been asked to pay a $1860.00 copayment for 5 days of Inpatient Hospital Care. This means that you have been asked to pay the correct amount based onyour 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 forinpatient hospital services provided September 14 to September 19, 2019
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered to the enrollee on June 19, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a
physician.
We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation.
Based on this information, we decided that Medicare rules for coverage of these services have not been met.
Therefore, we decided that the Plan does not have to pay for the drug testing rendered to the enrollee on June 19,
2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the Inogen G3 High Flow portable oxygen concentrator purchased on September 10, 2019.
You asked the Plan to reimburse you for the Inogen G3 portable oxygen concentrator. You say that you travel a lot and needed a portable oxygen concentrator. The Plan denied your request. The Plan says oxygen equipment purchased outright and not rented is never covered by Medicare.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. Medicare rules say that only rented oxygen equipment is eligible for coverage. Therefore, we decided that the Plan does not have to reimburse you for the Inogen G3 High Flow portable oxygen concentrator purchased on September 10, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on July 24, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says Healthcare Common Procedure Coding System (HCPCS) G0482 (1 Unit) remains not supported.
The Plan must follow Medicare rules. Medicare rules say that a physician order must be present for labs to be covered. The documentation submitted did not include a physician order/lab requisition or medical records stating exactly tests were to be performed. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for drug testing services provided to the enrollee on July 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve One Touch Ultra diabetic test strips.
You asked the Plan to pre-approve the One Touch Ultra test strips. You say that this is the brand of tests strips
that work with your meter. The Plan denied your request. The Plan says there is no medical reason noted that
you cannot use a meter and test strips from one of the preferred brands. A 90-day supply has been approved to
allow time to transition to and be trained on use of the preferred meter and strips.
The Plan must follow Medicare rules. Medicare rules say that Plans are allowed to restrict coverage of supplies
to specific brands as long as all medically necessary brands are available.
In this case, there is no documentation of a reason that the Plan's preferred brands would not be medically
appropriate. Without a clear reason why only the requested brand of strips can be used, we find that the rules
for coverage of the non-preferred brand have not been met. Therefore, we decided that the Plan does not have
to pre-approve One Touch Ultra diabetic test strips.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for Myocardial Perfusion Imaging (78452) performed November
12, 2019.
You asked the Plan to pay for Myocardial Perfusion Imaging. You say that the service was medically
necessary. The Plan denied your request. The Plan says Myocardial Perfusion Imaging is not listed on
Medicare's list of accepted screening tests.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.
The test at issue in this appeal, Myocardial Perfusion Imaging, was requested solely for screening purposes.
Medicare does not cover this test solely for screening purposes. The test performed is not on the list of
approved screening tests and there was no approved diagnosis code. Therefore, we decided that the Plan does
not have to pay for Myocardial Perfusion Imaging (78452) performed November 12, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for a Tetanus vaccination (90715) provided on October 9, 2019.
You asked the Plan to pay for the immunization. You say that the immunization was medically necessary for the member's health. The Plan denied your request. The Plan says some immunizations, such as TDAP, are covered under the Part D prescription drug benefit.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the immunization. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the immunization. Therefore, we decided that the Plan does not have to pay for a Tetanus vaccination (90715) provided on October 9, 2019.
Benefits for the immunization 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered to the enrollee on June 15, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a
physician.
We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation.
Based on this information, we decided that Medicare rules for coverage of these services have not been met.
Therefore, we decided that the Plan does not have to pay for the drug testing rendered on June
15, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve Computed Tomography of the Lumbar Spine (72131) and a Bone
Scan (78320).
You asked the Plan to pre-approve the scans. You say that the services are needed prior to surgery. The Plan
denied your request. The Plan says that the requested scans are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are
medically necessary.
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 scans. Our reviewer says that the
requested services are medically necessary. Our physician reviewer found in this case the patient is noted to
have worsening acute on chronic low back pain. They are being seen for pre-surgical work-up. In this setting it
would be reasonable and appropriate to have the patient undergo the requested procedures to further evaluate
the patient's spine to determine their candidacy for surgery.
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 scans have been met. Therefore, we decided that the Plan has to pre-approve
Computed Tomography of the Lumbar Spine (72131) and a Bone Scan (78320).
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical assistant services provided on a  treatment of femoral fracture (27236) on August 3, 2019.You asked the Plan to pay for surgical assistant services. You say that this service was medically necessary.The Plan denied your request. The Plan says this service is not covered for this type of provider.The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS.In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners.Therefore, we decided that the Plan does not have to pay for surgical assistant services provided on a  treatment of femoral fracture (27236) on August 3, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a laser cueing system for use on an approved walker.You asked the Plan to pre-approve the laser cueing system. You say that the enrollee has few options in order to help with their gait and the requested walker with laser is the best option.The Plan denied your request. The Plan says the walker has been approved; however, the laser beam cueing system is not considered to meet the definition of durable medical equipment.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. Although the use of a laser may be helpful in this case, the primary purpose for a laser pointer is not to treat an illness or injury.Therefore, we decided that the Plan does not have to pre-approve a laser cueing system for use on an approved walker.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for travel, meal and lodging expenses (S9975) incurred on April
3, 2019 through October 24, 2019.
You asked the Plan to pay for travel, meal and lodging expenses. You say that you would like reconsideration
as these services were related to your transplant. The Plan denied your request. The Plan says this benefit only
covers travel expenses for you and one companion for the evaluation and transplant, not for follow-up visits or
transplant related inpatient admissions after you receive your transplant.
The Plan must follow Medicare rules. Medicare rules say that in any circumstance in which an MA plan
provides transplant services at a more distant location, the MA plan must provide reasonable transportation and
accommodations.
We looked at the file and rules. Based on this information, we decided that Medicare rules for coverage of
travel, meal and lodging expenses. have not been met. Specifically, the Health Plan contract specifically states
that follow-up services after your transplant are not reimbursable. Therefore, we decided that the Plan does not
have to pay for travel, meal and lodging expenses (S9975) incurred on April 3, 2019 through October 24, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the panoramic x-ray (D0330), the limited oral evaluation (D0140), the surgical extractions (D7210 x 28), the alveoloplasty with extractions (D7310 x 2), the collection and application of autologous blood concentrate product (D7921), the implants (D6010 x 9), the unspecified adjunctive procedures (D9999 x 6), and the maxilliofacial prosthesis (D5999) that you received from September 11, 2017 to November 17, 2017.
You asked the Plan to reimburse you for the dental services. You say that the dental services that you received should be reviewed as medical. The Plan denied your request. The Plan says the services that you received are dental in nature. The Plan says that the dental services 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 dental services that you received are not among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for the panoramic x-ray (D0330), the limited oral evaluation (D0140), the surgical extractions (D7210 x 28), the alveoloplasty with extractions (D7310 x 2), the collection and application of autologous blood concentrate product (D7921), the implants (D6010 x 9), the unspecified adjunctive procedures (D9999 x 6), and the maxilliofacial prosthesis (D5999) that you received from September 11, 2017 to November 17, 2017.