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

We decided that the Plan does not have to pre-approvea group 3 power wheelchair (K0856).You asked the Plan to pre-approvea group 3 power wheelchair (K0856). You say that the requested group 3 power wheelchair is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested group 3 power wheelchair.The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 group 3 power wheelchair (K0856). Our reviewer says that the enrollee does not meet criteria for the requested group 3 power wheelchair. Our physician reviewer found the member has a relevant past medical history that includes ankle and foot Charcot's joint and acquired absence of right toes. He was seen for an evaluation on 03/16/2020. He had a primary complaint of being unable to go out into the community safely and independently. He was a functional ambulator within his home with the assistance of a standardcane. His mobility was limited to short distances due to developing pressure ulcers on the plantar surfaces of both feet when ambulating for long periods of time. He was receiving 24 hours of in-home support services. He had also purchased a standard wheelchair which he reported being unable to use due to the limited range of motion of his left arm. When attending to his instrumental activities of daily living he required use of a scooter to complete basic shopping needs. Physical examination findings included limited active range of motion of the left upper extremity above the shoulder. During the assessment he was able to ambulate 45 feet normally and up to 300 feet with his cane. He was able to complete most basic activities of daily living at a modifiedindependent level. The member does not have a covered indication for a Group 3 power wheelchair. There is no evidence that his mobility impairment cannot be resolved through the use of standard mobility aids such as a walker or optimally configured manual wheelchair.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 group 3 power wheelchair (K0856) have not been met.Therefore, we decided that the Plan does not have to pre-approvea group 3 power wheelchair (K0856).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the deductible forthe office visit provided on October 1, 2019.You asked the Plan to reduce the deductible forthe office visit. You say that you should only pay a $5 copayment and not almost $100 for a routine visit.The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $1,500 deductible that applies towards out-of-network office visits.The office visit you asked the Plan to reduce the deductible for falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,500 deductible that applies towards out-of-network office visits. The record shows you were seen for an office visit by an out-of-network provider. This cost sharing is a contractual obligation that had not been met at the time the office visitwas received on October 1, 2019.Therefore, we decided that the Plan does not have to reduce the deductible fortheoffice visit provided on October 1, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you forthe walk-in tub/shower purchased on August 19, 2019.You asked the Plan to reimburse you forthe walk-in tub/shower. You say that you had fallen twice whileclimbingin and out of your tub so you selected the walk-in tub/showerfor safety reasons.The Plan denied your request. The Plan says walk-in tubs are not considered medical equipment for which payment can be made.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Medicare does not cover home modifications.Therefore, we decided that the Plan does not have to reimburse you forthe walk-in tub/shower purchased on August 19, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe laboratory services provided on December 7, 2019.You asked the Plan to waive the copayment forthe laboratory services. You say that it was recommended to have these tests twice a year. You say that the thyroid tests should be covered in full as preventive.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 a $15 copayment for each Medicare-covered lab test. You have been asked to pay a $15 copayment for the laboratory services. The laboratory servicesfall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The laboratoryservicesare considered diagnosticservices. 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 forthe laboratory services provided on December 7, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a clinic visit (T1015) provided on October 23, 2019.You asked the Plan to pay for a clinic visit. You say that the massages you received helped with your tendonitis and sleep apnea.The Plan denied your request. The Plan says you previously reached your maximumof 6 visits for the year.The rules say that acupuncture services are not covered by Medicare and the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 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 up to 6 visits a year for the benefit program. We looked at the fileand Medicare rules. The record shows that you received 6 clinicvisits in 2019 prior to the date of service at issue. This means you have exceeded the benefit limit for this service. Based on this information, we decided that Medicare rules for coverage of a clinic visit have not been met.Therefore, we decided that the Plan does not have to pay for a clinic visit (T1015) provided on October 23, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe Trulicity 1.5mg/0.5ml medication (J3490).You asked the Plan to pre-approvethis medication. You say that this medication is medically necessary for the enrollee as this medication is helping to keep her blood sugars under control.The Plan denied your request. The Plan says thismedication is a benefit exclusion under the member's contractual policy.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approvethe Trulicity 1.5mg/0.5ml medication (J3490).Benefits for this medicationmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ultraviolet light therapy system provided onJune 24, 2019.You asked the Plan to pay forthe ultraviolet light therapy system. The Plan denied your request. The Plan says this is not medically necessary.The Plan follows Medicare rules. Medicare rules say that ultraviolet cabinets are covered for selected patients with generalized intractable psoriasis.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 ultraviolet light therapy system. Our reviewer says that the ultraviolet light therapy system was not medically reasonable and necessary. Our physician reviewer found there is no documented diagnosis for which an ultraviolet light therapy system would be indicated.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 ultraviolet light therapy system have not been met.Therefore, we decided that the Plan does not have to pay forthe ultraviolet light therapy system provided on June 24, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay fordrug testing services provided to the enrollee on April 24, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthe records do not support the service billed.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 Plandoes not haveto pay fordrug testing services provided to the enrollee on April 24, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for radiation treatments provided on December 13, 2019 and December 16, 2019. You asked the Plan to waive the copayment for radiation treatments. You say that the cost is a lot. You say that you want help with the copayment. The Plan denied your request. The Plan says the copayments 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 a $60 copayment for each Medicare-covered, in-network, radiation (radium and isotope) therapy service. You have been asked to pay a $60 copayment for each radiation treatment. The total amount you owe is $120 ($60/treatment x 2 treatments = $120). The radiation treatments fall within the "Outpatient diagnostic tests and therapeutic services and supplies" 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 radiation treatments provided on December 13, 2019 and December 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 16, 2019 to October 17, 2019 by an out of network (OON) provider. You asked the Plan to pay for practitioner visits. You say that the facility provides this nurse for the residents. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and the referring facility is also out-of-network with 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 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 the medical services provided on August 16, 2019 to October 17, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endovenous ablation therapy 1st vein (36475) and injection of non-compounded foam sclerosant (36465). You asked the Plan to pre-approve endovenous ablation therapy 1st vein and injection of non-compounded foam sclerosant. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met. The Plan follows Medicare rules. Medicare rules say that Endovenous Radiofrequency and Laser Ablation Occlusion Therapy is covered when specific criteria is 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 endovenous ablation therapy 1st vein and injection of non-compounded foam sclerosant. Our reviewer says that the services are not medically necessary. Our physician reviewer found the review has determined that you do not meet the coverage criteria. The requested items at issue in this case are not medically reasonable and 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 endovenous ablation therapy 1st vein and injection of non-compounded foam sclerosant have not been met. Therefore, we decided that the Plan does not have to pre-approve endovenous ablation therapy 1st vein (36475) and injection of non-compounded foam sclerosant (36465).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve podiatry services to be provided by an out of network (OON) provider. You asked the Plan to pre-approve podiatry services. You say that this doctor is open very Tuesday and the doctor is located right by a bus stop. The Plan denied your request. The Plan says these services can be provided in-network. The Plan says that they cannot approve this office visit. 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 podiatry services to be provided by an out of network (OON) provider.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Esbriet Tablets 267 mg. You asked the Plan to pre-approve Esbriet Tablets 267 mg. You say that you are appealing the denial because the enrollee has idiopathic pulmonary fibrosis and is responding well to treatment. The Plan denied your request. The Plan says this is an oral medication that is not covered under the Part B 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 Esbriet Tablets 267 mg.Benefits for Esbriet Tablets 267 mg 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 7, 2019 by an out of network (OON) provider. You asked the Plan to pay for the OON services. You say that you were suffering and grabbed the opportunity with the spine surgeon. The Plan denied your request. The Plan says the routine services were not authorized by 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 provider at issue in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services. We found no exception that would require the Plan to pay for these OON services. Therefore, we decided that the Plan does not have to pay for the medical services provided on October 7, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the cost share for the knee injection or the Part B injection provided on December 19, 2019.You asked the Plan to reduce the cost share for the knee injection and the Part B injection. You say that you have this same service in the past and only paid $11.86.The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $400 copayment for in-network Medicare-covered outpatient hospital surgery services and 20% coinsurance for in-network Medicare-covered Part B chemotherapy and prescription drugs. You have been asked to pay total of $94.20 for the knee injection and the Part B injection. The knee injection falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The Part B injection falls within the "Medicare Part B prescription drugs" benefit category. The record shows you were billed by an outpatient hospital. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to reduce the cost share for the knee injection and the Part B injection provided by on December 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not have to pre-approve percutaneous tibial nerve stimulation. You asked the Plan to pre-approve the stimulation. You say that this is medically necessary.The Plan denied your request. The Plan says there is a lack of medical necessity. 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 stimulation. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the medical records provided do not indicate that stress incontinence has been addressed. Behavior modification has not been tried. Also, it is unclear that you have had an adequate trial of anticholinergic medication treatment. 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 stimulation have not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous tibial nerve stimulation.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on August 29, 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 the records do not support the services billed. 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 August 29, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe chest x-ray provided to the enrollee on November 18, 2019.You asked the Plan to pay forthe x-ray. The Plan denied your request. The Plan says there is no diagnosis indicating this test.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, the x-ray, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes.Therefore, we decided that the Plan does not have to pay forthe chest x-ray provided to the enrollee on November 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveright lateral sacral radiofrequency ablation for the enrollee.You asked the Planto pre-approvethe injection. You say that this is medically necessary.The Plandenied your request. The Plansaysthere is an incomplete assessment of the benefit vs harm for this procedure.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 injection. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is considered experimental and investigational, due to the wide variation in efficacy in the peer-reviewed literature. Therefore, it is considered not medically reasonable or 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 injection have not been met.Therefore, we decided that the Plandoes not haveto pre-approveright lateral sacral radiofrequency ablation for the enrollee.