Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. You say that you need the therapy so you can go home and regain functionality.The Plan denied your request. The Plan says your records show that your care is no longer complex, and you do not need a team of providers. The Plan also says that you can safely receive the services you need in other settings.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer found that you do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. Our physician reviewer also found that there is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.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-approveacute IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction services (92015) provided September 21, 
2020. 
 
You asked the Plan to pay for the eye refraction services. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says eye refraction services are only 
covered when performed during a routine eye exam. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers eye refraction services when they are performed during a routine eye exam. 
 
We looked at the file and the Plan's rules. The file indicates that you received the eye refraction services during 
a medical eye exam and not for a routine eye exam. Based on this information, we decided that the Plan's rules 
for coverage of the eye refraction services have not been met. Therefore, we decided that the Plan does not 
have to pay for the eye refraction services (92015) provided September 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the POV, group 1 standard, patient weight capacity up 
to and including 300 pounds (CPT Code K0800). 
 
You asked the Plan to pre-approve the POV. You say that the POV is necessary. The Plan denied your request. 
The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The scooter is to be used outside of the home for community mobility. It does not indicate that the enrollee 
needs a scooter to help them perform activities of daily living in their home, or that a walker or manual 
wheelchair cannot safely meet the enrollee's needs for mobility in their home.  Additionally, records stated the 
enrollee has a walker that they use inside their home and short distances in the community. The enrollee not 
meet the Medicare rules for a scooter. Therefore, the request for an authorization for a motorized scooter has 
been denied Therefore, we decided that the Plan does not have to pre-approve the POV, group 1 standard, 
patient weight capacity up to and including 300 pounds (CPT Code K0800).
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to reimburse you for the transcutaneous electrical nerve stimulation (TENS) device purchased on July 24, 2020.

You asked the Plan to reimburse you for the TENS device. You say that the TENS device gives you the best relief for painful spasms. The Plan denied your request. The Plan says that criteria for a TENS device is not met.

Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. You were referred for the TENS device by a contract provider. The file does not show that the Plan provided notice that the TENS device would not be covered. Under Medicare rules, this means the TENS device is considered approved by the Plan. Therefore, we decided that the Plan has to reimburse you for the transcutaneous electrical nerve stimulation (TENS) device purchased on July 24, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe comprehensive periodontal evaluation and periodontal scaling and root planing provided on September 29, 2020, and October 13, 2020.You asked the Plan to pay forthe comprehensive periodontal evaluation and scaling and planing. You say that prior to receiving these services you contacted the Plan and were told they would be covered.The Plan denied your request. The Plan says youreceived a non-covered periodontal evaluation and as well as non-covered periodontal maintenance.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. The Plan confirmed that you did contact the Plan on May 11, 2020, but you did not inquire about periodontal services. The Plan says that you asked about the network participation of the provider, and were given the covered preventive dental benefits available under your plan.Therefore, we decided that the Plan does not have to pay forthe comprehensive periodontal evaluation and periodontal scaling and root planing provided on September 29, 2020, and October 13, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home infusion therapy rendered from April 16, 2020 to September 3, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit forhome infusion therapy services or supplies.We looked at the file and Medicare and the Plan's rules. Based on this information, we decided that Medicare and the Plan's rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay forthe home infusion therapy rendered from April 16, 2020 to September 3, 2020.Benefits for these servicesmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay forthe office or other outpatient visit provided September 22, 2020.You asked the Plan to pay forthe office or other outpatient visit. You say that you would like this claim reprocessed for medical necessity.The Plan denied your request. The Plan says when a member is enrolled in a Medicare-certified hospice program, the member's hospice services and members Part A and Part B services are paid for by original Medicare.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay forthe office or other outpatient visit provided September 22, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveRepatha Sureclick.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says self-administered drugs are not covered.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-approveRepatha Sureclick.Benefits for these servicesmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided to you from July 30, 2020, to September 10, 2020.
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says out-of-network dental services are not covered.
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 services are not among those covered under this benefit. The dental services in question were provided by an out-of-network provider. You are responsible to pay 100% of the cost of dental services provided by an out-of-network provider. Therefore, we decided that the Plan does not have to pay for the dental services provided to you from July 30, 2020, to September 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveendodontic therapy for tooth #12 (D3320).You asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The Plansaysthis 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.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 Plandoes not haveto pre-approveendodontic therapy for tooth #12 (D3320).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe intraoral, complete series of radiographic images(D0210) provided on September 10, 2020.You asked the Plan to pay forthis service. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says this service is not a covered benefit under your contractual policy.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 service provided is not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe intraoral, complete series of radiographic images(D0210) provided on September 10, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Omeprazole cap.
You asked the Plan to pre-approve Omeprazole cap. You say that you want the enrollee treated with this drug. The Plan denied your request. The Plan says this drug is not covered under the enrollee's Medicare 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 Omeprazole cap.
Benefits for Omeprazole cap 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: Unfavorable

We decided that the Plan does not have to pay for the ambulance service provided on June 30, 2020.
You asked the Plan to pay for the ambulance service. You say that the ambulance service was medically
necessary. The Plan denied your request. The Plan says the enrollee could have been safely transported by
another type of vehicle.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan
follows the same rules.
We looked at the file and Medicare rules. The record shows the enrollee, complaining of leg pain for a month,
was ambulatory, conscious, stable, in no acute respiratory or cardiac distress and had no sign of injury, stroke,
or hemorrhage. Neither oxygen nor emergency treatment was needed for transport. Based on this information,
we decided that Medicare rules for coverage of the ambulance service have not been met. Therefore, we
decided that the Plan does not have to pay for the ambulance service provided on June 30, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe emergency room (ER) services rendered on October 13, 2020.You asked the Plan to waive the copayment forthese services. You say that you had to go to the ER because you were misdiagnosed.The Plan denied your request. The Plan says the copayment was 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 $90 copayment for emergency care. Review of the file shows that you received ER services on October 13, 2020. You have been asked to pay a $90 copayment for these services. These services fall within the emergency care 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 thePlan. Therefore, we decided that the Plan does not have to waive the copayment forthe emergency room (ER) services rendered on October 13, 2020.Your complaint about the physician assistant is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the knee orthosis provided on June 25, 2020.
You asked the Plan to waive the coinsurance for the orthosis. You say that because you could not use the brace, you should not be responsible for the charges. The Plan denied your request. The Plan says that the cost share 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 20% coinsurance for each Medicare-covered prosthetic or orthotic device. You have been asked to pay a 20% coinsurance for the orthosis. The orthosis falls within the Medicare-covered prosthetic or orthotic device 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 coinsurance for the knee orthosis provided on June 25, 2020.
Appeal type: Testing
Decision: Partially Favorable

We decided that the Plan has to waive the copayment for the pacemaker check. We decided that the Plan does not have to waive the copayment for the pacemaker check.
You asked the Plan to waive the copayment for the pacemaker check. You say that you already paid a $40 copayment and you do not feel you should have to pay another copayment for your pacemaker check. The Plan says that you have been charged the correct cost sharing amount.
We decided that the Plan has to reduce the copayment for the pacemaker check.
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles, and coinsurance). The records show that a pacemaker check is a non-radiological diagnostic test. The Plan says that you must pay $34.38 for the pacemaker check. Based on the plan contract, however, you cannot be asked to pay more than a $6 copayment for the pacemaker check. Therefore, we decided that the Plan has to reduce the copayment for the pacemaker check from a $34.38 copayment to a $6 copayment.
We also decided that the Plan does not have to waive the copayment for the pacemaker check.
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 $6 copayment for the pacemaker check. Therefore, we decided that the Plan does not have to waive the copayment for the pacemaker check.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gelsyn.
You asked the Plan to pre-approve Gelsyn. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug does not meet step therapy criteria.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Gelsyn. Our reviewer says that the documentation does not support that the requested drug is medically reasonable or necessary. Our physician reviewer found the enrollee has pain related to osteoarthritis of the left knee, diagnosis confirmed with imaging studies. The documentation does not support that the enrollee has tried and failed Orthovisc and Monovisc. The documentation does not support any indication that the Plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Gelsyn have not been met. Therefore, we decided that the Plan does not have to pre-approve Gelsyn.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe computed tomography (CT) scan of the head/brain rendered on September 7, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 70450 is not separately payable.The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.The provider submitted a claim for procedure codes 70450 and 70496. Code 70450 is a v
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee.You asked the Plan to pre-approveIRF care. You say that IRF admission is medically necessary.The Plan denied your request. The Plan says Medicare coverage criteria are not met.The Plan must follow Medicare rules. The rules say that IRF admission is covered only whenit is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found thecomplexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient had a total hip replacement on January 20, 2021 and was discharged home with home health care. She continues to have pain and trouble ambulating. Medical conditionsare stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs.The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program.There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.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-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (D9250) for the enrollee. You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this 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. 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 pre-approve dental services (D9250) for the enrollee.