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

We decided that the Plan does not have to pay for the endodontic therapy (D3330) provided on August 13, 2020.
You asked the Plan to pay for the endodontic therapy. You say that these services were necessary. The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the endodontic therapy (D3330) provided on August 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on October 24, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 had network providers available who could have provided the services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-network provider on October 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for the recliner chair and the seat lift
mechanism provided on October 13, 2020.
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration
of the Plan's denial for payment. The Plan denied your request. The Plan says you do not meet Medicare
criteria for coverage of a recliner chair and a seat lift mechanism. Additionally, these items were purchased
from a non-Medicare provider.
The Plan must follow Medicare rules. The rules say that Medicare will pay for durable medical equipment that
is mainly used to serve a medical purpose. The rules also say that a seat lift mechanism is covered if all of the
conditions listed above are met. Additionally, no provider or supplier shall receive payment for services
furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare program.
We looked at the case file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of a recliner chair and seat lift mechanism have not been met. Specifically, a recliner chair is not
durable medical equipment that is mainly used to serve a medical purpose. The documentation provided does
not indicate that you meet Medicare criteria for coverage of a seat lift mechanism as the record does not
indicate that you have severe arthritis of the hip or knee or have a severe neuromuscular disease. The
documentation provided does not indicate that the seat lift mechanism is part of your treating practitioner's
course of treatment and prescribed to improve, or stop deterioration of, your condition. The letter written by
your physician indicated that you would benefit from a lift chair as you may have difficulties using a traditional
right handed recliner chair due to right shoulder surgery. The record does not indicate that you are completely
incapable of standing from a chair in your home. Additionally, these items were purchased from a durable
medical supplier that does not participate in the Medicare program. Therefore, we decided that the Plan does
not have to issue reimbursement for the recliner chair and the seat lift mechanism provided on October 13,
2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided from April 18, 2020, to August 9, 2020.
You asked the Plan to waive the copayment for the emergency room visit. You say that you do not have to pay a copayment an emergency room visit if you are admitted to the hospital and that you have a $0 copayment for observation. 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 $120 copayment for emergency services provided at an in-network emergency room. You have been asked to pay a $120 copayment for the emergency room visit from August 8, 2020, to August 9, 2020. The emergency room visit falls within the "Emergency care" benefit category. The record shows you were seen in the emergency room and kept in observation which is considered an outpatient service.
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 emergency room visit provided from April 18, 2020, to August 9, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient care provided from September 30, 2020, to
October 1, 2020.
You asked the Plan to pay for the inpatient care. The Plan denied your request. The Plan says the enrollee was
stable for transfer.
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider,
approval is required.
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 inpatient care. Our reviewer says that the
requested inpatient care was not medically reasonable and necessary. Our physician reviewer found that all
inpatient care provided after 2:05 pm from September 30, 2020, through 8:00 pm on October 1, 2020, was not
needed on an emergent basis. As of this time, the enrollee was hemodynamically and neurologically stable and
appropriate for ambulance transport with monitoring to a plan facility. The post-stabilization care services from
2:06 pm on September 30, 2020, were not medically necessary or reasonable. The treating physician did not
document (in the physician notes, on a form, or in an order) that the patient was not stable for transfer on any
dates of service.
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 inpatient care have not been met. Therefore, we decided that the Plan does
not have to pay for the inpatient care provided from September 30, 2020, to October 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical procedure for isolation of tooth with rubber dam (D3910) and the unspecified endodontic service (D3999) provided on September 10, 2020.
You asked the Plan to pay for the dental services. You say that no one ever told you that the procedure was not covered. You say that you have already paid $985 out of pocket. You say that you do not have an Evidence of Coverage paper or book. You also say that you had a root canal many years ago with no problem. The Plan denied your request. The Plan says surgical procedure for isolation of tooth with rubber dam is not listed as a covered service. The Plan also says that unspecified endodontic service is not listed as a covered service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for surgical procedure for isolation of tooth with rubber dam (D3910) and the unspecified endodontic service (D3999) provided on September 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the remainder of the dental services provided on October 14, 2020.
You asked the Plan to pay for the dental services. You say that the Plan should pay this claim. The Plan denied your request. The Plan says after paying $184 on this claim the enrollee has reached the $500 non-Medicare covered dental allowance.
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 claim exceeds this benefit allowance. Therefore, we decided that the Plan does not have to pay for the remainder of the dental services provided on October 14, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided  on July 22, 2020.
You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on July 22, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on July 22, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on April 19, 2020.
You asked the Plan to pay for the medical services. You say that the services rendered to the enrollee were medically necessary. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on April 13, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the medical services provided on April 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on September 2, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the physician's services. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on September 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the foot orthotics (L3000 x 2) provided on August 14, 2020.
You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that the enrollee does not meet Medicare criteria for coverage of the foot orthotics provided.
Medicare rules say that inserts and other shoe modifications (L3000) are covered if they are on a shoe that is an integral part of a covered brace and if they are medically necessary for the proper functioning of the brace. The record shows that the orthotics provided are not on a shoe that is an integral part of a covered brace. Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of orthotics for her condition. Therefore, we decided that the Plan does not have to pay for the foot orthotics (L3000 x 2) provided on August 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Dexcom G6 receiver, transmitter and sensor for the enrollee.
You asked the Plan to pre-approve a Dexcom G6 receiver, transmitter and sensor for the enrollee. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that the enrollee does not meet criteria for coverage.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a Dexcom G6 receiver, transmitter and sensor for the enrollee have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 receiver, transmitter and sensor for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the outpatient physician services provided on April 12, 2020, and April
13, 2020, during a hospital observation stay.
You asked the Plan to pay for the outpatient observation services. You say that the enrollee was treated by the
provider in the hospital after presenting to the emergency room for immediate medical attention. The Plan
denied your request. The Plan says that the services were not provided in a network facility, and no prior
authorization was provided by the Plan prior to treating this patient.
The Plan must follow Medicare rules. The rules say that an emergency exists based on a prudent layperson
standard, not a retrospective medical review. For symptoms to be considered emergent in nature, they must be
such that a prudent layperson with an average knowledge of medicine would reasonably expect the absence of
immediate medical attention would result in serious jeopardy to their health.
We decided that this case does meet prudent layperson criteria for emergency care. The enrollee was previously
discharged when it was planned that she would have assistance in the home. No assistance was available, and
the enrollee had multiple falls including one while trying to rise from a chair during which she was not able to
get up. A prudent layperson with an average knowledge of medicine would reasonably expect the absence of
immediate medical care to seriously jeopardize their health. Therefore, we decided that the Plan has to pay for
the outpatient physician services provided on April 12, 2020, and April 13, 2020, during a hospital observation
stay.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a Group 3 power wheelchair (PWC) controller input device upgrades (E2377, E2313, E2311).
You asked the Plan to preapprove the control input device upgrades. You say that the enrollee needs a Group 3 power wheelchair with power recline in addition to power tilt. The Plan denied your request. The Plan says they agreed to overturn the initial decision and found the Group 3 PWC was necessary, but the expandable controller upgrades were not.
The Plan must follow Medicare rules. The rules say that the approved power options come with their own switches. The electrical connection between the wheelchair controller and two or more motors (E2311), expandable controller (E2377) and harness (E2313) cannot be covered. Although there are three approved power options on this wheelchair (tilt, recline and elevating leg rests), there is not a medical need to control these power options through the joystick. Member has 4/5 strength in the left upper limbs. Able to perform feeding, bathing, dressing independently. Member's upper limb strength and function are therefore adequate for the member to be able to control the power options using their own switches which are included in the allowance of these power options. The rules also indicate that this exceeds the member's needs. Therefore, we decided that the Plan does not have to preapprove a Group 3 power wheelchair (PWC) controller input device upgrades (E2377, E2313, E2311).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided on August 14, 2020.
You asked the Plan to pay for the self-administered drugs. You say that these drugs were necessary. The Plan
denied your request. The Plan says self-administered drugs are not covered while you are in the hospital.
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 pay for the self-administered drugs
provided on August 14, 2020.
Benefits for the self-administered drugs 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: Transportation
Decision: Favorable

We decided that the Plan has to pay for the ambulance transportation provided on October 8, 2020.
You asked the Plan to pay for the ambulance transportation. You say that the Plan denied your request. The Plan says that the services were not medically necessary.
Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules. 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 ambulance transportation. Our reviewer says that the requested ambulance transportation is medically reasonable and necessary. Our physician reviewer found that the enrollee did require the expertise of trained personnel or the equipment available only on an ambulance in order to effectuate a safe transport. Transportation could not have been provided by other means (stretcher van, wheelchair van, private car, taxi) without endangering the enrollee's condition. A prudent layperson would believe that immediate medical attention was required for an intoxicated patient reporting trauma. 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 ambulance transportation have been met. Therefore, we decided that the Plan has to pay for the ambulance transportation provided on October 8, 2020.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on by an out of network (OON) provider on November 15, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by an out-of-network provider without prior authorization.
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 referring provider is not a network provider with the Plan. The Plan had network providers available who could have provided 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 laboratory services provided on by an out of network (OON) provider on November 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on October 27, 2020.
You asked the Plan to pay for the comprehensive oral evaluation. You say that you would like this service to be covered. The Plan denied your request. The Plan says this service exceeds the frequency limitation in your benefit plan.
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, comprehensive oral evaluation (D0150) is limited to one procedure every three plan years. The record shows that you received a comprehensive oral evaluation (D0150) on January 22, 2020, and your comprehensive oral evaluation (D0150) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on October 27, 2020.