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

We decided that the Plan has to pay forthe home glucose monitor, blood glucose test strips, and lancets provided on September 27, 2019.You asked the Plan to pay forthe home glucose monitor, blood glucose test strips, and lancets. You say that you would like the plan to reconsider theirdenial.The Plan denied your request. The Plan says that the services billed are misrepresented services.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward tothe IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Review of the file shows that the plan claims that these items billed are a misrepresentation of services. The plan uses a Medicare fraud and abuse rule to support their denial. However, nothing in the file shows that these services were fraud or abuse. The documentation provided by the plan doesnot specifically in any way show proof that these services are not payable. Therefore, we decided that the Plan has to pay forthe home glucose monitor, blood glucose test strips, and lancets provided on September 27, 2019.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 more for the eyeglass lenses you received on August 2, 2019.
You asked the Plan to pay more for the lenses. The Plan denied your request. The Plan says the benefit limit was reached.
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 these services up to a $100 benefit limit per calendar year. We looked at the file and the Plan's rules. The records show that you were provided eyeglass lenses on August 2, 2019. The lenses were billed for $389. The plan paid $100 toward the lenses. You are responsible for the amount over the $100 plan benefit limit ($289). Therefore, we decided that the Plan does not have to pay more for the eyeglass lenses you received on August 2, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous positive airway pressure device (CPAP).
You asked the Plan to pre-approve continuous positive airway pressure device (E0601). You say that you have excessive fatigue and need a CPAP. The Plan denied your request. The Plan says the sleep study shows you do not qualify for a CPAP.
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. The documentation shows your sleep study AHI was 4.7. Based on this information, we decided that Medicare rules for coverage of continuous positive airway pressure device (CPAP) have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous positive airway pressure device (CPAP).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the DME provided to the enrollee from April 14, 2018 through April 25, 2018, an out-of-network provider.You asked the Plan to pay forthe DME. You say that the durable medical equipment is medically necessary.The Plan denied your request. The Plan says the services were not authorized.Medicarerules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe DME provided to the enrollee from April 14, 2018 through April 25, 2018, an out-of-network provider.
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 enrollee has been unable to wean due to shortness of breath and difficulty breathing.The Plan denied your request. The Plan says the requested IRF care is not medically necessary.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 theenrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the enrollee's medical status requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit from and participate in additional physical and occupational therapy, but has poor endurance and does not require this on an intensive rehabilitation facility therapy programlevel 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.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe inpatient stay provided from June 5, 2019 through June 7, 2019.You asked the Plan to waive the copayment forthe inpatient stay. You say that you cannot afford to pay the bill.The Plan denied your request. The Plan says the copayment applied correctly.The rules saya 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 $450 copayment each day for days 1 to 4 for Medicare-covered hospital care.You have been asked to pay a $450 copayment for the inpatient stay. ($450/day x 2 days = $900). The inpatient stay falls within the "Inpatient hospital care" benefit category. This means that you have been asked to pay the correctamount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment forthe inpatient stay provided from June 5, 2019 through June 7, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a wrist orthosis (L3916) provided September 18, 2019.
You asked the Plan to pay for the orthosis. You say that the item was medically necessary. The Plan denied your request. The Plan says there is no record of an existing relationship between the enrollee and the telehealth provider who ordered the orthosis.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. There is no evidence of an established relationship between the enrollee and the prescribing telehealth provider. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for a wrist orthosis (L3916) provided September 18, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that you fainted due to dangerously low potassium levels. You were treated by a medic at your home and then transported by one ambulance to the hospital. You say that the services should be covered because the call was medically necessary and you did not know that two ambulances would answer the call. You say that the cost is an unnecessary financial hardship. 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 September 21, 2019. 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.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay fora screening Mammogram (77067) provided September 25, 2019.You asked the Plan to pay forthe mammogram. You say that the mammogram was performed by an in-network provider and you have no control over the radiologist the provider used to read the mammogram. You have not paid for screening mammograms in the past.The Plan denied your request. The Plan says that the radiologist that read the screening mammogram is out-of-network despite the provider that performed it being in-network. The plan states they contacted the provider by phone who advised that the member signed a consent form stating the radiologist bills separately.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 mammogram by a contract provider. The file does not show that the plan  provided notice that the mammogram would not be covered. While the plan states that they contacted the provider by phone-who stated the enrollee was provided notice-no copy of this signed notice was provided to the IRE for review. Under Medicare rules, this means the mammogram is considered approved by the plan.Therefore, we decided that the Plan has to pay fora screening Mammogram (77067) provided September 25, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rituximab injection services.
You asked the Plan to pre-approve the Rituximab injection services. You say that the requested drug is medically necessary. The Plan denied your request. The Plan says there is not enough scientific evidence to show that the requested drug is safe or effective for treatment of the enrollee's diagnosis of Polymyositis.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the Rituximab injection services. Our reviewer says that the requested Rituximab injection services are not medically reasonable and necessary. Our physician reviewer found the use of Rituximab is being requested for the treatment of Polymyositis. Our physician reviewer found that the compendia does not support the use of Rituximab for the treatment of this diagnosis. Medical necessity for the requested drug has not been established by the records provided. 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 Rituximab injection services have not been met. Therefore, we decided that the Plan does not have to pre-approve Rituximab injection services.
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 enrollee's needs cannot be safely met with home health services or a skilled nursing facility (SNF) at this time. You say that the enrollee's ability to regain maximum function would e greatly jeopardized without this level of care. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The plan says that the records show that the enrollee can safely receive the services needed in another setting.
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 enrollee was medically stable with no evidence of need for supervision by a physical medicine and rehabilitation physician. The enrollee does not have needs for acute rehab nursing care. The enrollee may benefit from further physical therapy and occupational therapy, but does not require an intensive therapy program. An IRF admission is not medically necessary based on the enrollee's current functional status and medical stability. 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 the bone replacement grafts, first site in quadrant, (D4263) for teeth # 2 and 15, and the bone replacement grafts, each additional tooth, (D4264) for teeth # 4, 6, 8, 9, 11, and 13.
You asked the Plan to pre-approve the dental services. You say that the dental services are necessary. The Plan denied your request. The Plan says the bone replacement grafts are not 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 bone replacement grafts are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the bone replacement grafts, first site in quadrant, (D4263) for teeth # 2 and 15, and the bone replacement grafts, each additional tooth, (D4264) for teeth # 4, 6, 8, 9, 11, and 13.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Enbrel (J1438).
You asked the Plan to pre-approve the Enbrel. You say that the Enbrel is medically necessary as the member has tried and failed other formularies. The Plan denied your request. The Plan says drug coverage for the member is limited to Medicare Part B covered drugs.
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 Enbrel (J1438).
Benefits for the Enbrel 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
You asked the Plan to pre-approve the compression stockings. You say that these items are necessary and should be covered because if you do not use them your legs will swell. The Plan denied your request. The Plan says these items are non-covered when used for swollen legs or varicose veins.
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6530 are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound. The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you do not have a medical condition for which compression stockings can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series of intraoral x-rays (code D0210) and two prophylaxes (code D1110) provided on January 15, 2019 and July 16, 2019.You asked the Plan to pay for the intraoral x-rays and prophylaxes. You say that you checked with the provider and the Plan and were told that this provider was in-network with your plan.The Plan denied your request. The Plan says this provider is not part of the Plan's network. The Plan also says that no benefits are available for procedures performed by out-of-network providers.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 out-of-network.Therefore, we decided that the Plan does not have to pay forthe complete series of intraoral x-rays (code D0210) and two prophylaxes (code D1110) provided on January 15, 2019 and July 16, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided November 5, 2017 & November 6, 2017.
You asked the Plan to pay for the skilled nursing services. You say that the services that the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says Skilled Nursing Facility (SNF) care beyond 100 days per benefit period is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. The file shows that the enrollee received 100 days of SNF care during the benefit period from May 11, 2017 to November 4, 2017. The Plan has covered 100 days of SNF care. Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. the enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided on November 5, 2017 and November 6, 2017.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the periodontal scaling and root planing (D4341) for all 4 quadrants.You asked the Plan to pre-approvethe dental services. You say that you have diabetes. You say that you have bleeding and it is causing and infection. You say that the scaling and root planing needs to be completed.The Plan denied your request. The Plan says scaling and root planing is not 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 scaling and root planning is not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvethe periodontal scaling and root planing (D4341) for all 4 quadrants.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve OneTouch Verio Test Strips.You asked the Plan to pre-approvethe non-preferred brand of glucose test strips. You say that the enrollee has adexterity impairment.The Plan denied your request. The Plan says the information provided does not support medical necessity for the non-preferred brand.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. You have not provided documentation that the non-preferred brand is necessary to avoid an adverse medical outcome. Based on this information, we decided that Medicare rules for coverage of the non-preferred brand of glucose test strips have not been met.Therefore, we decided that the Plan does not have to pre-approveOneTouch VerioTest Strips.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered to the enrollee on September 17, 2019.
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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing rendered to the enrollee on September 17, 2019.