Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea referral to an out-of-referral circle provider.You asked the Plan to pre-approvethe referral. You say that this is medically necessary.The Plan denied your request. The Plan says your PCP has certain network specialists they use for physical therapy.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 plan has certain network specialists to use for physical therapy. This is not the preferred provider with your PCP for physical therapy. The Plan has preferred 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-approvea referral to an out-of-referral circle provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approve IRF care. You say that the requested IRF care is medically necessary for the enrollee's treatment following a total hip replacement surgery. The appellant says that the nursing home that the enrollee was directed to was not helpful in the enrollee's recovery after his last hip replacement.The Plan denied your request. The Plan says the documentation fails to indicatethat he enrollee requires medical practitioner assessment or intervention at least 3 times per week or greater, specialized therapeutic skills or equipment, and rehabilitation nursing services available 24 hours per day.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a SNF level of care. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a skilled nursing facility (SNF). The enrollee is mostly minimal to standby assist for functional transfers and activities of daily living. A less intensive, longer duration of therapy will allow for measurable gains to be achieved within a predicted period.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on May 31, 2019. 
 
You asked the Plan to waive the copayment for the office visit. You say that you told the doctor you were allergic to the drug. You say that the five minutes the doctor saw you doesn't constitute an office visit. The Plan denied your request. The Plan says the copayment applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $15 for each covered visit or consultation in an outpatient location with a specialist.  
 
You have been asked to pay a $15 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show that the office visit was for major depressive disorder. 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 office visit provided on May 31, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics (L3000).
You asked the Plan to pre-approve foot orthotics (L3000). You say that you would like the Plan to reconsider their denial. 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 (L3000).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for specialist services provided on January 29, 2020 by an out of
network (OON) provider.
You asked the Plan to pay for specialist services. You say that you have not had any success with in-network
providers. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that
there are multiple in-network providers available for these services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to 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 specialist services provided on January 29, 2020
by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99201), a neurological procedure (95999) and x-ray (72020) provided on March 3, 2020.
You asked the Plan to pay for the chiropractic services. You say that you would like reconsideration because you were told you needed this care prior to surgery. The Plan denied your request. The Plan says your coverage is limited to manual manipulation of the spine when performed by a licensed chiropractor.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for an office visit (99201), a neurological procedure (95999) and x-ray (72020) provided on March 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the ski program under your Wellness Allowance.
You asked the Plan to pay for your ski pass. You say that you do not go to a gym, this is what you do. The Plan denied your request. The Plan says this program is not at a qualified health club or fitness facility.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers gym benefits only in a qualified health club or fitness facility. The Plan's rules for coverage of gym benefits have not been met because this is a sport activity. Therefore, we decided that the Plan does not have to pay for the ski program under your Wellness Allowance.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre Continuous Glucose Monitor.
You asked the Plan to pre-approve the continuous glucose monitor. You say that the continuous glucose monitor is medically necessary. The Plan denied your request. The Plan says coverage criteria was not met.
The Plan follows Medicare rules. Medicare rules say that continuous glucose monitors are covered when 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 continuous glucose monitor. Our reviewer says that the continuous glucose monitor is not medically necessary. Our physician reviewer found the enrollee does not use insulin injections and there is nothing in the record that shows the enrollee cannot use a traditional glucometer. 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 continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre Continuous Glucose Monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for intradialytic parenteral nutrition.You asked the Plan to pay for intradialytic parenteral nutrition. You say that the records provided should support the necessity of the requested service.The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay for intradialytic parenteral nutrition.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe first intraoral periapical x-ray provided on February 24, 2020.You asked the Plan to pay forthe first intraoral periapical x-ray. You say that your dentist told you the services would be covered. You also say that you do not have the money to pay for this service.The Plan denied your request. The Plan says this service is not a covered benefit.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 pay forthe first intraoral periapical x-ray provided on February 24, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on November 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 on November 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the ankle foot orthosis and the shoulder-elbow-wrist-hand
orthosis provided on October 17, 2019.
You asked the Plan to pay for the ankle foot orthosis (L1971) and the shoulder-elbow-wrist-hand orthosis
(L3960). You say that the orthoses were medically necessary. The Plan denied your request. The Plan says
rules for telehealth services were not 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 orthosis and the shoulder-elbowwrist-
hand orthosis provided on October 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99201) provided on February 26, 2020.You asked the Plan to pay for the office visit. You say that you would like reconsideration because this provider is board certified and his services should be covered.The Plan denied your request. The Plan says this provider is not eligible to participate in Medicare therefore you are responsible for the full cost of the services you receive.The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.The services at issue in this appeal were provided in a non-urgent, non-emergent situation. This provider has opted out of the Medicare program.Therefore, we decided that the Plan does not have to pay for an office visit (99201) provided on February 26, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 9 home health nursing visits.
You asked the Plan to pre-approve home health services. The Plan denied your request. The Plan says the enrollee has no defined skilled nursing needs.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 home health services. Our physician reviewer found that the documentation revealed no complex skilled nursing needs. The enrollee verbalized understanding of all medications. The records do not show that skilled nursing services are required to effectively provide treatment, care, or services in order to improve the enrollee's condition, or to establish/perform a maintenance program to maintain his condition, or prevent deterioration. The enrollee has no complex wound care, new enteral feedings, IV antibiotics or other SN need. He does not require the requested 9 home health SN 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 home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve 9 home health nursing visits.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 4 home health skilled nursing visits (G0299). 
 
You asked the Plan to pre-approve 4 home health skilled nursing visits. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 
 
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 4 home health skilled nursing visits. Our reviewer says that the services are not medically necessary. Our physician reviewer found there is a lack of objective indicators that support home-confinement. There is no indication that you could not benefit from nonskilled services, and/or outpatient care. As such, this request is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 4 home health skilled nursing visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 4 home health skilled nursing visits (G0299).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mastectomy sleeve. 
 
You asked the Plan to pre-approve a mastectomy sleeve. The Plan denied your request. The Plan says that this is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that a mastectomy sleeve is noncovered because it does not meet the definition of a prosthesis. Therefore, we decided that the Plan does not have to pre-approve a mastectomy sleeve.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Restasis Mul Emu 0.05%.
You asked the Plan to pre-approve Restasis Mul Emu 0.05%. You say that the medication is necessary. The
Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit or a
separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for
coverage.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Restasis Mul Emu 0.05%.
Benefits for Restasis Mul Emu 0.05% 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 pay for the bitewing x-rays (D0274) provided on January 16, 2020.
You asked the Plan to pay for the dental service. You say that the preventive dental services that are covered
include 2 oral exams, 2 cleanings, 1 dental x-ray, and 1 fluoride treatment every year. You say that nowhere
does it say bitewing x-rays are not covered. You also say that you would not have gotten the x-rays had you
known they were not going to be covered. The Plan denied your request. The Plan says you did not elect to
purchase the optional supplemental dental benefit. The Plan says that bitewing x-rays are 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, bitewing x-rays are not among those
covered under this benefit. The Evidence of Coverage clearly lists intraoral complete series of x-rays and
panoramic x-rays as the only dental x-rays that are covered. Therefore, we decided that the Plan does not have
to pay for the bitewing x-rays (D0274) provided on January 16, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approve IRF care. You say that [Enter appellant's argument from appeal letter, e.g. "...you need SNF care."]The Plan denied your request. The Plan says[Enter plan denial rationale, e.g. "...rules for SNF care have not been met."]The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found you do not require the intensity of services provided at an IRF. Specifically, you are not shown to require, or to be able to perform, fifteen hours per week of rehabilitative services with regular physician evaluation. Your 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 Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on February 28, 2020.
You asked the Plan to pay for the physician's services. 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 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
physician's services. 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 physician's services provided on February 28, 2020.