Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation (A0425, A0428) received June 10, 2020.

You asked the Plan to waive the copayment for the ambulance transportation. You say that the ambulance bill was expensive, and you would appreciate relief from the copayment. The Plan denied your request. The Plan says the correct cost share applied to the claim.

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 $265 copayment for Ambulance Services. 

You have been asked to pay a $265 copayment for the ambulance transportation. The ambulance transportation falls within the Ambulance Services 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 the ambulance transportation (A0425, A0428) received June 10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the enrollee requires close daily oversight of care in an inpatient setting. The Plan denied your request. The Plan says the enrollee's care is routine, and she does not need a team of providers.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

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 physician reviewer found that the enrollee was admitted to the acute care hospital for surgical repair of a hip fracture after a fall. Her medical conditions are stable. There are no complex nursing needs. She does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program.

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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.

You asked the Plan to pre-approve SNF services. You say that SNF admission is medically necessary for the enrollee to continue to improve their current medical condition. The Plan denied your request. The Plan says Medicare coverage criteria are not met.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 there are no required skilled nursing services are identified. Also, the documentation does not support that skilled services are required daily in a skilled nursing facility on an inpatient basis. 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 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve infusion set for external insulin pump, non-needle cannulas type (CPT code A4230), for the enrollee.

You asked the Plan to pre-approve the pump. You say that you do not know why the enrollee's pump is being denied. The Plan denied your request. The Plan says this code is included in code A4224. The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the pump have not been met. The rules say that codes A4230 (infusion set for external insulin pump, non-needle cannulas type) and A4231 (infusion set for external insulin pump, needle type) are not valid for claim submission to the DME MAC because they are included in code A4224. Use A4223 for infusion supplies not used with a covered external infusion pump. Therefore, we decided that the Plan does not have to pre-approve infusion set for external insulin pump, non-needle cannulas type (CPT code A4230), for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says you do not require an intensive and coordinated interdisciplinary approach to rehab.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

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 physician reviewer found that you were admitted to the acute care hospital for stroke and dysarthria. Your medical conditions are stable. The complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental implants (D6010) for teeth #3, #13 and #14.

You asked the Plan to pre-approve dental implants. You say that these implants are necessary. The Plan denied your request. The Plan says implants are only covered when they are used to replace one tooth in the same part of your mouth. This request is to replace three teeth in the upper jaw. There may also be other treatment options to replace these missing teeth.

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. The Plan can cover dental implants when they are medically necessary and when a single tooth is missing in an arch or as support for an implant supported full denture when there is inadequate bone to support a denture or a history of a failed attempt at retaining a denture.

We looked at the file and Medicare rules. The request is for three implants in the same arch. There is no indication that this request is related to supporting a denture due to inadequate bone support or a history of a failed attempt to retain a denture. In addition, no medical records or x-rays were provided with this request. Based on this information, we decided that the Plan's rules for coverage of dental implants have not been met. Therefore, we decided that the Plan does not have to pre-approve dental implants (D6010) for teeth #3, #13 and #14.
Appeal type: Practitioner Services
Decision: Unfavorable

You asked the Plan to pre-approve the consultation. You say that the enrollee had an ultrasound done on June 30, 2021, and are requesting to see the provider to have the results read on July 20, 2021. The Plan denied your request. The Plan says this provider is not in the enrollee's network and the enrollee can receive the services from 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. 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 the consultation to be provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the upgraded electronics or bracket.

You asked the Plan to pre-approve a power wheelchair expandable controller (E2377), power wheelchair expandable controller harness (E2313), power wheelchair electronic connection (E2311), and bracket assembly (K0108). You say that the enrollee needs a Group 3 power wheelchair and accessories The Plan denied your request. The Plan says although there are three approved power options on the wheelchair there is not a medical need to control the power options through the joystick and the bracket is included in the approved seat cushion.

The Plan must follow Medicare rules. The rule say options and accessories for wheelchairs are covered if the beneficiary has a wheelchair that meets Medicare coverage criteria and the option/accessory itself is medically necessary. 

The bracket assembly at issue in this appeal cannot be paid separately. The record shows upper limb strength and function are adequate for the enrollee to control the power options using their own switches which are included in the allowance of the power options. Therefore, we decided that the Plan does not have to pre-approve the upgraded electronics or bracket assembly.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve SNF care. You say that you need SNF care. The Plan denied your request. 
The Plan says the rules for SNF care have 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 in the Medicare rules section 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 that the patient has diabetes, 
coronary artery disease, end stage renal dialysis on dialysis, and cognitive deficits. In this case, there are no 
identifiable skilled nursing service needs and no identifiable skilled therapy service needs. In addition, you do 
not require skilled nursing or therapy services on a daily basis. In conclusion, you do not meet severity of 
illness or intensity of service criteria for 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 admission to a skilled nursing facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis (D1110) provided on August 13, 2020 by a Medicare opt out provider.

You asked the Plan to pay for the prophylaxis. You say that you feel this claim was submitted under the incorrect plan. The Plan denied your request. The Plan says this service was rendered by a provider who has opted out of Medicare.

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 covered when they are received by a Medicare opt out provider. Therefore, we decided that the Plan does not have to pay for the prophylaxis (D1110) provided on August 13, 2020 by a Medicare opt out provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the non-elastic binder for an extremity (A4465) and gradient compression stocking (A6549).

You asked the Plan to pre-approve the non-elastic binder for an extremity and gradient compression stocking. You say that these items are medically necessary. The Plan denied your request. The Plan says these are not covered benefits under Medicare.

The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are noncovered because they do not meet the statutory definition of a surgical dressing. The rules also say that non-elastic binder for an extremity are also noncovered because they also do not meet the statutory definition of a surgical dressing. 

Although these items may be appropriate, they do not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve the non-elastic binder for an extremity (A4465) and gradient compression stocking (A6549).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia 60 mg/ml syringe for the enrollee.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your
request. The Plan says this is being dispensed for self-administration.

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 Prolia 60 mg/ml syringe for
the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation (A0429) received March 4, 2021.

You asked the Plan to waive the copayment for the ambulance transportation. You say that you would like the Plan to waive the copayment. The Plan denied your request. The Plan says the correct cost share applied to the claim.

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 $200 copayment for Ambulance Services. 

You have been asked to pay a $200 copayment for the ambulance transportation. The ambulance transportation falls within the Ambulance Services 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 the ambulance transportation (A0429) received March 4, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the physical therapy visits to be provided by an out-of-network provider.

You asked the Plan to pre-approve the physical therapy visits. You say that this provider is close to your home and you prefer to do your therapy close to home. The Plan denied your request. The Plan says this provider is not in your network and you can receive the services from 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. 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 the physical therapy visits to be provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two custom fabricated abutments (D6057 x2), two abutment supported porcelain fused to metal crowns (D6059 x2), drugs or medicaments dispensed in the office for home use (D9630), core buildup, including any pins when required (D2950), two crowns (D2750 x2), two periodontal maintenances (D4910 x2), and extraction (D7140) provided from February 5, 2020, to October 20, 2020.

You asked the Plan to pay for the custom fabricated abutments, abutment supported crown, drugs or medicaments, core buildup, crowns, periodontal maintenances, and extraction. You say that you have a $2,000 dental benefit limit. The Plan denied your request. The Plan says the custom fabricated abutment, abutment supported crown, and drugs or medicaments are not covered benefits. The Plan also says that you are responsible for the coinsurance amounts for the core buildup, crown, periodontal maintenance, and extraction.

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 custom fabricated abutment, abutment supported crown, and drugs or medicaments are not among those covered under this benefit. You are responsible for a 70% coinsurance for the core buildup, including any pins when required (D2950) and crown (D2750) that is received OON. You are also responsible for a 50% coinsurance for the periodontal maintenance (D4910) and extraction (D7140) that is received OON. Therefore, we decided that the Plan does not have to pay for the two custom fabricated abutments (D6057 x2), two abutment supported porcelain fused to metal crowns (D6059 x2), drugs or medicaments dispensed in the office for home use (D9630), core buildup, including any pins when required (D2950), two crowns (D2750 x2), two periodontal maintenances (D4910 x2), and extraction (D7140) provided from February 5, 2020, to October 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for digital hearing aids (V5261) purchased on October 27, 2020.

You asked the Plan to pay for the hearing aids. You say that these hearing aids were necessary. The Plan
denied your request. The Plan says the hearing aids were not purchased from the Plan's specified vendor, and
therefore cannot be covered.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for
hearing aids only when they are purchased from a provider in the Plan's specified hearing network.

We looked at the file and the Plan's rules. These hearing aids were purchased from a provider outside the Plan's
specified hearing vendor network. Based on this information, we decided that the Plan's rules for coverage of
the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for digital hearing
aids (V5261) purchased on October 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Kinova Jaco 2 robotic arm left-handed (E1399) Kinova
Lift arm (E1399).

You asked the Plan to pre-approve a robotic arm to attach to wheelchair. You say that you are unable to open
doors in your own home or in the community. This will provide a dramatic improvement in your safety as you
can exit a room or building in case of an emergency or if your caregiver is not available. The Plan denied your
request. The Plan says robotic arms for your wheelchair are not medically necessary and is not covered by
Medicare.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of a robotic arm to attach to wheelchair have not been met. Therefore, we decided that the Plan does
not have to pre-approve Kinova Jaco 2 robotic arm left-handed (E1399) Kinova Lift arm (E1399).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for a periodic oral evaluation (D0120), a teeth cleaning (D1110), a filling (D2391), and an unspecified preventive procedure (D1999) provided from August 12, 2020, through August 19, 2020.

You asked the Plan to pay an additional amount for a periodic oral evaluation, a teeth cleaning, a filling, and an unspecified preventive procedure. You say that you were told that the provider was in-network. The Plan denied your request. The Plan says the provider was paid at the Medicare allowed rate therefore no additional payment can be made. An unspecified preventive procedure 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. 

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a periodic oral evaluation, a teeth cleaning, a filling, and an unspecified preventive procedure have not been met. Specifically, the allowed amount of the periodic oral evaluation, teeth cleaning, and filling for an out-of-network provider were paid by the plan. Additionally, an unspecified preventive procedure is not a covered benefit. Therefore, we decided that the Plan does not have to pay an additional amount for a periodic oral evaluation (D0120), a teeth cleaning (D1110), a filling (D2391), and an unspecified preventive procedure (D1999) provided from August 12, 2020, through August 19, 2020.