Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the full amount for the oral exam (D0120) and cleaning (D1110) provided on December 9, 2019 by an out of network provider.You asked the Plan to pay the full amount for the dental services. You say that your insurance covers 2 cleanings per year. You also say that you received a bill where only $52 of $134 was paid.The Plan denied your request. The Plan says the provider in this case is not a network provider. The Plan says that services that you receive out of network are subject to a higher cost share.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 and oral exams and cleanings are covered services, there is a 50% coinsurance when you receive these services out of network.Therefore, we decided that the Plan does not have to pay an additional amount for the oral exam (D0120) and cleaning (D1110) provided on December 9, 2019 by an out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecustom shoe inserts.You asked the Plan to pre-approvecustom shoe inserts. You say that custom she inserts are medically necessaryfor use with an "AFO".The Plan denied your request. The Plan says Medicare coverage criteria are not met.Medicare rules state that supportive devices for the feet (such as custom shoe inserts) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.  The Records show that you do not suffer from diabetic foot disease and you do not wear a leg bracein which the inserts would be part of the original cost. Although custom she inserts may be appropriate for you, neither Medicare nor the Plan provides coverage of inserts for your condition.Therefore, we decided that the Plan does not have to pre-approvecustom shoe inserts.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair and accessories to be provided by an out of network (OON) provider.You asked the Plan to pre-approve these services. You say that you require a new power wheelchair.The Plan denied your request. The Plan says that these services can be provided in 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 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 a power wheelchair and accessories to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment for the specialist office visit provided on March 14, 2019.You asked the Plan to waive the copayment for the specialist office visit. You say that this appointment should be covered under the 90-day global period. The Plan denied your request. The Plan says that you have been charged the correct cost sharing amount. The Plan says the carpal tunnel surgery is a minor surgery and has a10-day global period.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 enrollees must pay $45 copayment for provider and professional services in an in-network specialist's office. The Plan says you must pay a $45 copayment for the specialist office visit. Based on the Plan contract, however, you cannot be asked to pay more than $0 copayment for the specialist office visit. The record shows there is a 90-day global period for the carpal tunnel surgery (64721). The specialist office visit on March 14, 2019 falls within the 90-day global period. Therefore, we decided that the Plan has to waive the copayment fora specialist office visit provided on March 14, 2019. 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient admission for a total knee arthroplasty.
You asked the Plan to pre-approve an inpatient admission. The Plan denied your request. The Plan says there is no clinical evidence to support untold perioperative events are to be expected.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. 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 an inpatient admission. Our physician reviewer found that the enrollee is to undergo a procedure, which is not on the inpatient only list, and is not expected to require two midnights of inpatient level care. There is no documentation of uncontrolled co-morbidities pre-procedure, which are clearly expected to necessitate a prolonged stay. The enrollee should present for the surgery as an outpatient. Should complications arise, necessitating a prolonged stay, the enrollee can be converted to inpatient status, at that time. Therefore, the requested inpatient admission is not medically necessary at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an inpatient admission have not been met. Therefore, we decided that the Plan does not have to pre-approve an inpatient admission for a total knee arthroplasty.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics and management.You asked the Plan to pre-approve foot orthotics. You say that the services are needed to have the enrollee return to pain free, functional mobility and an independent activity.The Plan denied your request. The Plan says the enrollee does not have documented diabetic foot disease.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.  The records do not show that the enrollee suffers from diabetic foot disease and does not wear a leg brace. Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of orthotics for the enrollee's condition.Therefore, we decided that the Plan does not have to pre-approve foot orthotics and management.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the re-cement or re-bond of a crown provided on December23, 2019.You asked the Plan to pay for re-cement or re-bond of a crown. You say that you had a crown come off and feel this service was necessary.The Plan denied your request. The Plan says the benefits for this service have been satisfied and the frequency limitation has been exceeded.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, recementation and is limited to one procedure every five years. The record shows that you received a re-cement of a crown on March 20, 2018 and February 19, 2019 and your recementation benefit has been exhausted.Therefore, we decided that the Plan does not have to pay for the re-cement or re-bond of a crown provided on December 23, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that you need further assistance with recovery. The Plan denied your request. The Plan says that custodial care is not covered.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
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 you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services are not medically necessary.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 required maximum assistance with bed mobility, transfers, walking, and lower body dressing. You required minimal assistance with upper body dressing. You were medically stable with no evidence of need for supervision by physical medicine and rehabilitation physician or needs acute rehab nursing care. While you may benefit from further physical therapy and occupational therapy, you do not require an intensive rehabilitation therapy program. Your therapy needs can be met at a lower level of care.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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested admission is not medically necessary.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonableand necessary in this case. Our physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital for multifocal pneumonia and acute respiratory distress syndrome in the setting of metastatic prostate cancer. The enrollee was intubated/ventilated. The enrollee remains on a ventilator and is requiring frequent ventilator changes to stabilize his respiratory status. The enrollee does not appear to be ready for ventilator weaning. There is no evidence that the enrollee requiresservices that are not currently available. As LTACHs and acute care hospitals are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current acute care hospital untilsuch time no acute services are required.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 LTACH services have not been met.Therefore, we decided that thePlan does not have to pre-approvelong term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Guardian sensors for continuous glucose monitor.You asked the Plan to pre-approve Guardian sensors. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested items are not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that code A9276 (disposable sensors) describe supplies used with a non-therapeutic continuous glucose monitoring (CGM) system.We looked at the file and Medicare rules. Review of the file shows that you are requesting Guardian sensors identified with code A9276. Code A9276 describes supplies used with a non-therapeutic CGM. Only therapeutic CGM and supplies are covered. Based on this information, we decided that Medicare rules for coverage of Guardian sensors have not been met.Therefore, we decided that the Plan does not have to pre-approve Guardian sensors for continuous glucose monitor.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadditional routine transportation trips.You asked the Plan to pre-approveadditional routine transportation trips. The Plan denied your request. The Plan says that you have exceeded your benefit limit.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 twenty-four (24) trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation.Therefore, we decided that the Plan does not have to pre-approveadditional routine transportation trips.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider at the in-network rate.

You asked the Plan to pre-approve OON services to be provided at the in-network rate. You say that you would like the plan to reconsider their decision. The Plan denied your request. The Plan says the requested services can be provided by a network provider.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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. While you may receive services from OON providers, your share of the costs may be higher. 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 to be provided at the in network rate. Therefore, we decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider at the in-network rate.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an annual routine physical examination provided on November 19, 2019.You asked the Plan to pay for annual physical exam. You say that this was a follow-up visit.The Plan denied your request. The Plan says the denial of payment for this service is correct, because you received an annual routine physical on May 17, 2019 and therefore this benefit was exhausted.The Plan must follow Medicare rules. Your contract with the Plan says that the annual routine physical examination is covered once per calendar year. We looked at the file and your contract with the Plan. You received an annual routine physical exam on May 17, 2019; therefore, this visit exceeded the limit of 1 exam per calendar year. Based on this information, we decided that the Plan's rules for coverage of annual physical exam have not been met.Therefore, we decided that the Plan does not have to pay for an annual routine physical examination provided on November 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the home ventilator, any type, used with non-invasive interface (E0466).You asked the Plan to pre-approve the ventilator. You say that the medical records should support the necessity of the service in dispute.The Plan denied your request. The Plan says the Medicare criteria for coverage were not met.The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD.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 ventilator. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found Coverage criteria for a home ventilator are not met because the enrollee is not using the device sufficiently to derive benefit. The enrollee has muscular dystrophy, a covered diagnosis. However, usage for at least 4 hours is only 2% of days. This does not meet the minimum criteria of at least 70% of days. Therefore the ventilator 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 the ventilator have not been met.Therefore, we decided that the Plan does not have to pre-approve the home ventilator, any type, used with non-invasive interface (E0466).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient hospital care as of May 15, 2020.You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee is in need of skilled nursing service and is refusing medication when her family gives it to her.The Plan denied your request. The Plan says the denial of authorization for acute inpatient hospital care is correct.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient care are met in this case. Our physician reviewer found the enrollee presented to the emergency department for increased confusion. She only complained of knee pain, but otherwise no other findings or test results were suggestive of an acute process. The enrollee agreed to discharge to an assisted living facility once stable. Based on the documentation provided, prior to admission there was insufficient support suggesting that at least a 2-midnight stay was required.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met.Therefore, we decided that the Plan does not have to pre-approve inpatient hospital care as of May 15, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay foran MRI of the lumbar spine (72148) provided on December 2, 2019.You asked the Plan to pay forthe MRI. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the submitted medical records do not contain sufficient detail to support the billed charges.The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the MRI have not been met. Specifically, the record does not include the actual date of service.Therefore, we decided that the Plan does not have to pay foran MRI of the lumbar spine (72148) provided on December 2, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a heavy duty extra wide hospital bed.
You asked the Plan to pre-approve a heavy duty extra wide hospital bed. You say that you need this because if you roll over in your current bed you would fall off. The Plan denied your request. The Plan says that you do not meet requirements for coverage.
The Plan must follow Medicare rules. Medicare rules say that a heavy duty extra wide hospital bed is covered if the beneficiary's weight is more than 350 pounds, but does not exceed 600 pounds. We looked at the file and Medicare rules. The file indicates you do not weigh between 350 and 600 pounds. Based on this information, we decided that Medicare rules for coverage of a heavy duty extra wide hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve a heavy duty extra wide hospital bed.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for polycarbonate lens (V2784) progressive lens (V2781) and
anti-reflective coating (V2750) purchased January 14, 2020.
You asked the Plan to pay for the lens enhancements. You say that with your other insurances you have never
been denied. You paid out of pocket $327.96 The Plan denied your request. The Plan says lens enhancements
are not covered under the plan benefits.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan coverage is limited to single vision, lined bifocal and lined trifocal lenses.
We looked at the file and the Plan's rules. lens enhancements are not covered under the plan benefits. Based on
this information, we decided that the Plan's rules for coverage of the lens enhancements have not been met.
Therefore, we decided that the Plan does not have to pay for polycarbonate lens (V2784) progressive lens
(V2781) and anti-reflective coating (V2750) purchased January 14, 2020.