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

We decided that the Plan does not have to pre-approve a manual wheelchair.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that a manual wheelchair is covered when specific criteria are met. 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 these services. Our reviewer says that the enrollee does not meet the criteria for coverage. Our physician reviewer found the records do not show that the enrollee has a enrollee has a mobility limitation that significantly impairs her ability to participate in one or more mobility-related activities of daily living. The documentation does not reveal that the enrollee's mobility limitation cannot be sufficiently and safely resolved by the use of an appropriately fitted cane or walker. The documentation does not reveal that the enrollee's home provides adequate access for the requested wheelchair and that the use of the wheelchair will significantly improve the enrollee's mobility-related activities of daily living. We looked at this physician's review, the file, and Medicare rules. 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 pre-approve a manual wheelchair.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMEMs device.
You asked the Plan to pre-approve a CardioMEMs device. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have 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 a CardioMEMs device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the efficacy of the CardioMEMS heart failure system remains uncertain at this time. Further clinical study is needed to determine the efficacy and safety of this device. It is not clear that the CardioMEMS device is medically reasonable and necessary for the enrollee in this case. 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 CardioMEMs device ha
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on October 17, 2019.
You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says 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 an emergent situation that 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 services 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 a domiciliary, rest home visit provided on October 17, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extractions (D7210 x 10), the initial 15 minutes of deep sedation (D9222), and the additional 15 minutes of deep sedation (D9223 x 2) provided on October 26, 2020.
You asked the Plan to pay for the dental services. You say that nothing was paid on this claim. You say that the dentist filed the claim for the dentures before the oral surgeon because you had immediate dentures put in, so you got the dentures before you saw the oral surgeon. You say that is why the claims were in a different order. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that out of network providers are allowed to bill you for the difference of the allowed amount and the amount billed. The Plan says there is a 50% coinsurance for anesthesia. The Plan also says that extractions are not payable after you receive dentures.
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, out of network dental providers can bill you for the different between the billed amount and the allowed amount. There is a 50% coinsurance for the anesthesia. This is a contractual obligation you agreed to when you enrolled in the Plan's dental coverage. Additionally, the record shows that you received dentures on October 19, 2020, prior to the date of service in this case. Extractions are not covered after you receive dentures. Therefore, we decided that the Plan does not have to pay for the extractions (D7210 x 10), the initial 15 minutes of deep sedation (D9222), and the additional 15 minutes of deep sedation (D9223 x 2) provided on October 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an endosteal implant, custom fabricated abutment, and abutment supported porcelain/ceramic crown.
You asked the Plan to pre-approve the endosteal implant, custom fabricated abutment, and abutment supported porcelain/ceramic crown. You say that you feel these services should be covered. The Plan denied your request. The Plan says these services are not included under your benefit plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an endosteal implant, custom fabricated abutment, and abutment supported porcelain/ceramic crown.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic continuous glucose monitor and supplies provided November 17, 2020.
You asked the Plan to pay for the therapeutic continuous glucose monitor and supplies. You say that this item was medically necessary for the enrollee. The Plan denied your request. The Plan says criteria for the continuous glucose monitor has not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of the therapeutic continuous glucose monitor and supplies have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic continuous glucose monitor and supplies provided November 17, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Praluent 75 mg/mL injection.

You asked the Plan to pre-approve Praluent. You say that this request is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this drug is not covered under the medical benefit.

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 Praluent 75 mg/mL injection.

Benefits for Praluent 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services rendered on November 21, 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 the services were unauthorized post-stabilization.
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. 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 these services. Our reviewer says that the enrollee was stable for transfer to a network facility. Our physician reviewer found the enrollee presented to the emergency room (ER) with complaints of generalized weakness and dysuria. He was admitted to the medical surgical unit for initial assessment of a urinary tract infection and to rule out bradycardia, dysrhythmia, hypertension, anemia, hypokalemia, and acute kidney injury. The enrollee was hemodynamically stable and appropriate for ambulance transport with monitoring to a plan facility after the ER evaluation. There is no documentation necessitating post-stabilization care services at the non-Plan facility. The treating physician did not document (in the physician notes, on a form, or in an order) that the enrollee was not stable for transfer on any dates of service. We looked at this physician's review, the file, and Medicare rules. 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 inpatient hospital services rendered on November 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit coded 99281.

You asked the Plan to pay for the emergency department visit. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the
documentation.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.

In this case, the CPT Code Manual definition of code 99281 is emergency department visit for the evaluation
and management of a patient, which requires these 3 key components: A problem focused history; A problem
focused examination; and Straightforward medical decision making. Counseling and/or coordination of care
with other physicians, other qualified health care professionals, or agencies are provided consistent with the
nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are selflimited
or minor.

We find that CPT code 99281 is not supported in the medical record. Specifically, the documentation supports
one unit of this code. One unit of this code was previously approved and paid. There is no additional
documentation supporting additional services of this code. Based on this information, we decided that
Medicare rules for coverage of the emergency department visit have not been met. Therefore, we decided that
the Plan does not have to pay for the emergency department visit coded 99281.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the nursing facility visit provided by an out-of-network provider on November 23, 2020.
You asked the Plan to waive the deductible for the nursing facility visit. You say that this claims should not have a deductible assessed because doing so is discriminatory. The Plan denied your request. The Plan says this deductible was assessed appropriately.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $500 deductible for out-of-network services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible for out-of-network services. This cost sharing is a contractual obligation that had not been met at the time the nursing facility visit was provided on November 23, 2020. Therefore, we decided that the Plan does not have to waive the deductible for the nursing facility visit provided by an out-of-network provider on November 23, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation.
You asked the Plan to pre-approve additional routine transportation. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says you have used 45 of the allotted 48 one-way transportation trips. The Plan says additional trips will not be approved.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 48 one-way transportation trips per year. We looked at your request, the records in the case file, and the rules. The file shows that you have used 45 out of the allowed 48 total trips for the 2021 benefit year. Once you have used all 48 trips you will have exhausted your supplemental transportation benefit. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis coded L1833 and the addition orthosis
coded L2397 provided on October 2, 2020.
You asked the Plan to pay for the knee orthosis and the addition orthosis. You say that you would like the plan
to reconsider their denial. The Plan denied your request. The Plan says the items rendered are not a covered
benefit.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT codes L1833 and L2397 are not supported in the medical record. Specifically, the
documentation does not support a claim history for the prescribing provider on the date of service or in the last
six months prior to the date of service. Based on this information, we decided that Medicare rules for coverage
of the knee orthosis and the addition orthosis have not been met. Therefore, we decided that the Plan does not
have to pay for the knee orthosis coded L1833 and the addition orthosis coded L2397 provided on October 2,
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve elbow, wrist, hand, finger (EWHF) device powered, with single or double upright(s), any type joint(s), includes microprocessor, sensors, all components and accessories (L8702).
You asked the Plan to pre-approve the orthotic device. You say that given that traditional rehabilitation strategies have been tried and failed, the family physician has referred him for myoelectric orthotic restoration. The Plan denied your request. The Plan says the request does not meet the criteria as the procedure is considered experimental, investigational or unproven.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the orthotic device have not been met. Therefore, we decided that the Plan does not have to pre-approve elbow, wrist, hand, finger (EWHF) device powered, with single or double upright(s), any type joint(s), includes microprocessor, sensors, all components and accessories (L8702).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the shoulder elbow wrist hand orthosis (L3960).

You asked the Plan to pay for the shoulder elbow wrist hand orthosis. You say that the item provided was medically necessary for the enrollee. The Plan denied your request. The Plan says there is no established relationship between the prescribing physician and the member.

You asked the Plan to pay for the shoulder elbow wrist hand orthosis. You say that the item provided was medically necessary for the enrollee. The Plan denied your request. The Plan says there is no established relationship between the prescribing physician and the member.

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 the shoulder elbow wrist hand orthosis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found a physical examination of the shoulder would reasonably be required to adequately assess whether the shoulder/arm orthosis was medically necessary for an enrollee. The documentation does not support that the orthosis was medically reasonable and necessary for the enrollee in this case, as there is insufficient documentation of an appropriate evaluation, and a credible physical examination of the shoulder.

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 shoulder elbow wrist hand orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the shoulder elbow wrist hand orthosis (L3960).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device (HFCWOD).
You asked the Plan to pre-approve a HFCWOD. You say that this device is medically necessary. The Plan denied your request. The Plan says this is not medically necessary for your condition.
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases. 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 HFCWOD. Our reviewer says that the requested service is not medically necessary and reasonable. Our physician reviewer found the diagnosis of bronchiectasis has not been confirmed by CT scan. The elements of the local coverage determination are not satisfied. Therefore, the requested service cannot be recommended. 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 HFCWOD have not been met. Therefore, we decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device (HFCWOD).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis (L1833) and a suspension sleeve (L2397) provided on October 29, 2020.
You asked the Plan to pay for a knee orthosis and a suspension sleeve. You say that these items should be covered. The Plan denied your request. The Plan says these items are not supported by the documentation.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.
The record does not contain a valid physician order or relevant medical records which support medical necessity for the supplies provided in this case. The physician order does not include the suspension sleeve. The medical records also do not indicate that the items at issue were prescribed in connection to a valid telehealth visit with the enrollee's treating physician. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for a knee orthosis (L1833) and a suspension sleeve (L2397) provided on October 29, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a fine needle aspiration provided on September 18, 2020.
You asked the Plan to waive the copayment for a fine needle aspiration. You say that you disagree with how high the charges are. 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 $250 copayment for outpatient surgery. You have been asked to pay a $250 copayment for a fine needle aspiration. A fine needle aspiration falls within the outpatient surgery 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 copayment for a fine needle aspiration provided on September 18, 2020.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for the ambulance transportation to a skilled nursing facility provided on October 14, 2020.
You asked the Plan to pay for the ambulance transportation. The Plan denied your request. The Plan says that transportation to and from a doctor's office is not covered.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan says that ambulance transportation to and from a doctor's office is not a covered service. However, per Medicare rules, ambulance transportation is covered "from any point of origin to the nearest hospital or skilled nursing facility (SNF) capable of furnishing appropriate care for a patient's illness or injury". The Plan has not provided supporting documentation to substantiate its denial. Therefore, we decided that the Plan has to pay for the ambulance transportation to a skilled nursing facility provided on October 14, 2020.
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.