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

We decided that the Plan does not have to reimburse you forthe ultra-lightweight wheelchair purchased on October 16, 2019.You asked the Plan to reimburse you forthe ultra-lightweight wheelchair. You say that the wheelchair that was to be provided was too heavy and would not fit through your front door.The Plan denied your request. The Plan says you did not have authorization for the out-of-network purchase.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. The rules say that no Medicare payment may be made to a beneficiary for items provided directly by a provider who is not eligible to take Medicare payment. Durable medical equipment purchased privately through agents such as  are not eligible for coverage by your Medicare governed health plan. 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 reimburse you forthe ultra-lightweight wheelchair purchased on October 16, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. 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 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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment. You do not have a complex wound care or other SNF level skilled nursing need. Your functional status does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment only in a SNF. You do not require these skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis". As a practical matter you do not require the necessary services on an inpatient basis, in a skilled nursing facility setting. 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 care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve tooth extractions.You asked the Plan to pre-approve these services. You say that you need the teeth removed due to cavities.The Plan denied your request. The Plan says the services are not covered.Medicare generally does not cover dental services. The Plan follows the same rule.The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. The services are not covered by your medical benefit because the extractions are not being done to prepare the jaw for radiation treatments. The file shows that you are not enrolled in the Plan's optional supplemental dental benefit. Therefore, we decided that the Plan does not have to pre-approvetooth extractions.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forphysician services provided on April 30, 2019 by an out of network (OON) provider.You asked the Plan to pay forphysician services. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says no prior authorization was obtained.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 inthis 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 forphysician services provided on April 30, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Stiolto.You asked the Plan to pre-approve Stiolto. You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says Stiolto is not covered under the enrollee's Medicare Part B benefit.The Plan must follow Medicare rules. The rules say that Medicare Part Bgenerally 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-approveStiolto.Benefits for Stioltomay 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 waive the copayments forthe specialist office visits provided on September 17, 2019 and November 5, 2019.You asked the Plan to waive the copayments forthe specialist office visits. You say that you cannot afford the copayment. 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $30 copayment for each Tier 1 Medicare-covered specialist visits. The enrollee has been asked to pay a $30 copayment for each of the specialist office visits. The specialist office visits fall within the "Physician/Practitioner services, including doctor's office visits" benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractualobligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayments forthe specialist office visits provided on September 17, 2019 and November 5, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic exercises provided on October 21, 2019 and October 22, 2019.
You asked the Plan to pay for the therapeutic exercises. 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 emergency situation, 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 therapeutic exercises provided on October 21, 2019 and October 22, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Computed Tomography (CT) of the Thorax (71250) provided October 18, 2019 by Southtown Radiology.You asked the Plan to waive the copayment forthe CT scan. You say that the copayment should be waived.The Plan denied your request. The Plan says the correct copayment was applied.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $175 copayment for Diagnostic Imaging. You have been asked to pay a $166.66 copayment for the CT scan. The CT scan falls within the Diagnostic Imaging benefit category. The $166.66 maximum allowable amount is less than the $175 copayment stipulated in the contract. 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 haveto waive the copayment forComputed Tomography (CT) of the Thorax (71250) provided October 18, 2019 by Southtown Radiology.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the supply allowance for the continuous
glucose monitoring system on August 29, 2019.
You asked the Plan to pay for the supply allowance for the continuous glucose monitoring system. You say that
the CGM was medically necessary. The Plan denied your request. The Plan says the documents provided do
not support medical necessity.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they
are medically reasonable and necessary and replace a blood glucose monitor.
We looked at the file and Medicare rules. There is no record of an office visit at the time of the order and
therefore medical necessity is not supported. Based on this information, we decided that Medicare rules for
coverage of the supply allowance for a continuous glucose monitor have not been met. Therefore, we decided
that the Plan does not have to pay for the supply allowance for the  continuous glucose
monitoring system  on August 29, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for SNFcare provided from August 13, 2019 through August 23, 2019.You asked the Plan to waive the copayment for SNF care. You say that you have never been in a SNF before and you thought everything is covered by the insurance.The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received SNF care from August 13, 2019 through August 23, 2019. You are asked to pay a $20 copayment per day for the ten (10) days you were in SNF care. 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 SNF care provided from August 13, 2019 through August 23, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Buzzaround XL 3 wheel scooter.You asked the Plan to pre-approvea Group 1 power operated vehicle. You say that you need a scooter. The Plan denied your request. The Plan says there is no physician face-to-face or written order.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. The records show you are able to ambulate in the home. The Plan requested documentation from your physician but did not receive it. This means that Medicare rules for coverage of a PMD have not been met.Therefore, we decided that the Plan does not have to pre-approvea Buzzaround XL 3 wheel scooter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for knee orthosis (L1820) provided on November 7, 2019 by an out-of-network provider. You asked the Plan to waive the deductible for the durable medical equipment (DME). You say that you were seen by an in-network provider and were referred for the knee brace because you had a lot of pain and trouble walking. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received a knee orthosis (L1820) on November 7, 2019 by an out-of-network provider. At the time of services rendered you had not met your $1,000 deductible; therefore, you have been asked to pay $133.57 for the services to apply to your deductible. 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 deductible for knee orthosis (L1820) provided on November 7, 2019 by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on September 18,
2019.
You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says that
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 emergency
situation, 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 and the retirement facility in this case are not network providers 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 September 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on November 4, 2019.You asked the Plan to pay for the dental service. You say that per your 2020 enrollment guide, it clearly states that 3 routine cleaning are allowed per year.The Plan denied your request. The Plan says you received the peridodontal maintenance procedure in 2019. The Plan says that the 2019 Evidence of Coverage states periodontal maintenance is covered 2 times per plan year. The Plan also says the frequency limit 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 and periodontal maintenance is a covered service, the frequency limit has been exceeded. The record shows that the Plan paid for periodontal maintenance that you received on January 28, 2019 and April 29, 2019.Therefore, we decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on November 4, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a pneumatic compression device (E0652).
You asked the Plan to preapprove a pneumatic compression device. You say that the enrollee requires the device. The Plan denied your request. The Plan says the documentation did not support the necessity for more than the basic pump.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to preapprove a pneumatic compression device (E0652).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a white glass with high gold content cap for a bridge for tooth 3 & 5 (D6750) and a false tooth for a bridge for tooth 4 (D6240).
You asked the Plan to pre-approve a white glass with high gold content cap for a bridge for tooth 3 & 5 and a false tooth for a bridge for tooth 4. You say that the services are necessary since your ability to eat properly is effected and is causing severe gastrointestinal issues. 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. 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 white glass with high gold content cap for a bridge for tooth 3 & 5 and a false tooth for a bridge for tooth 4. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested bridge on this level is not medically necessary as the abutment teeth are not suitable for use with the appliance. In terms of coverage for bridgework under the Policy, fixed bridges are limited to the anterior of the mouth where there is one upper or two lower adjacent teeth missing. In this case there is one missing posterior tooth that is being requested to be replaced. There is no coverage for this type of appliance under the Plan even if the abutments were suitable for use. 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 white glass with high gold content cap for a bridge for tooth 3 & 5 and a false tooth for a bridge for tooth 4 have not been met. Therefore, we decided that the Plan does not have to pre-approve a white glass with high gold content cap for a bridge for tooth 3 & 5 (D6750) and a false tooth for a bridge for tooth 4 (D6240).
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 admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.
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 admission to an IRF does not meet criteria. Our physician reviewer found the member was admitted for acute care on 03/13/2020 after a mechanical fall while standing on a bus. She sustained a left hip fracture. She underwent open reduction with internal fixation and corticomedullary nail placement. She is weightbearing as tolerated. Her relevant past medical history includes osteoporosis and anemia. The member lives alone in an apartment and had been independent. Functionally, as of 03/23/2020 she required supervision for transitioning from seated to standing and minimal assistance when ambulating 8 feet. A progress note on 03/24/2020 indicates that she has orthostatic hypotension with stable blood pressure after fluids. Her pain was being well controlled. The member is status-post left hip fracture as described above without significant postoperative complication and is weightbearing as tolerated. The member's medical conditions appear stable. There are no complex wound care needs. There are no unaddressed medical issues. She does not require medical oversight of her condition at an acute hospital level of care. The member requires physical therapy for mobility and occupational therapy for remaining activities of daily living and adaptive equipment. She has a new unilateral lower extremity impairment without identified significant upper extremity impairment and does not require the intensity of an acute level rehabilitation therapy program. The member appears to be limited by pain after her recent surgery. She would not be expected to be able to fully participate in or benefit from the required intensity of an acute rehabilitation therapy program. There is no reason to think that an intensive rehabilitation therapy program would significantly impact the member's condition differently compared with therapy provided at a less intense level. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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.