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

We decided that the Plan does not have to pre-approve Carroll CS Series CS7 brand full electric bariatric bed.
You asked the Plan to pre-approve the long term care bed. You say that your neurologist specifically requested this specific bed so it is medically necessary for you to have this bed in order to improve sleep at night. The Plan denied your request. The Plan says the brand specific Carroll CS7 bed is not medically necessary. The plan had approved a fully electric hospital bed.
The Plan must follow Medicare rules. The rules say that a hospital bed may be considered medically necessary when at least one of the following criteria is met: 1. The patient has a medical conditions which requires positioning of the body in ways not feasible with an ordinary bed; or 2. The patient requires positioning of the body in ways not feasible with an ordinary bed in order to alleviate pain; or 3. The patient requires the head of the bed to be elevated more than 30 degrees most of the time due to congestive heart failure, chronic pulmonary disease, or problems with aspiration. Pillows or wedges must have been considered and ruled out; or 4. The patient requires traction equipment, which can only be attached to a hospital bed. 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 long term care bed. Our reviewer says that the specific brand name Carroll CS Series CS7 full electric bariatric bed, is not medically necessary over the bed offered by the plan. Our physician reviewer found the documentation reveals the enrollee was already approved a bariatric hospital bed that is fully electrical and has height adjustment settings to allow the enrollee to transfer from bed to chair and wheelchair. There are no extenuating factors on physical exam that require the specific brand name requested as the approved bed appears to meet the requests of the bed that the neurologist ordered.
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 long term care bed have not been met. Therefore, we decided that the Plan does not have to pre-approve Carroll CS Series CS7 brand full electric bariatric bed.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on September 25, 2019.
You asked the Plan to pay for the lab services. You say that you are the only provider for Guardant360 testing. 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 that it is the provider's responsibility to verify the member'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. 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 for the laboratory services provided on September 25, 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 forthe ambulance services. You say that the ambulance should have never been called. You say that once the ambulance arrived they checked and evaluated your vitals. You believe that you didn't need them and should not be held liable.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 November 4, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Planpays for the services provided.Therefore, we decided that the Plan does not have to pay forthe ambulance services
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.

You asked the Plan to pre-approve incontinence supplies. You say that you are appealing with medical records. The Plan denied your request. The Plan says this item is not a covered benefit.

The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a specialist office visit to be provided by an out of network provider.
You asked the Plan to pre-approve a specialist office visit. You say that you have not had success with any of the in-network doctors you have seen. The Plan denied your request. The Plan says there are multiple in-network providers available for these services.
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 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. 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 a specialist office visit to be provided by the out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the endodontic therapy and first intraoral periapical x-ray provided on October 7, 2019 and October 8, 2019.
You asked the Plan to pay for the endodontic therapy and first intraoral periapical x-ray. You say that your tooth broke out of your mouth and your dentist did emergency service for you. You also say that you cannot afford to pay for these services. The Plan denied your request. The Plan says endodontic therapy is not covered under the Plan. The Plan also says that the first intraoral periapical x-ray exceeds the maximum allowed per period.
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, endodontic therapy is not covered under this benefit. The contract also states that intraoral x-rays are limited to two procedures per plan year. The record shows that you received a first intraoral periapical x-ray on April 18, 2019 and on August 29, 2019 and your intraoral x-rays benefit was then exhausted. Therefore, we decided that the Plan does not have to pay for the endodontic therapy and first intraoral periapical x-ray provided on October 7, 2019 and October 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ear wax removal provided on September 30, 2019.You asked the Plan to waive the copayment forthe ear wax removal. You say that you were told there would be no copayment to remove the wax out of your ear. You say this was a part of your wellness exam. 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 $50 copayment for each in-network specialist office visit for Medicare-covered services. You have been asked to pay a $50 copayment for the ear wax removal. The ear wax removal falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. Therecord shows the ear wax removal is a considered a surgical service that was performed by an otolaryngologist. Therefore, this service was performed in addition to your wellness exam.This means that you have been asked to pay the correct amount based onyour 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 ear wax removal provided on September 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have waive the copayment for physician's services foran eye exam provided on July 29, 2019.You asked the Plan waive the copaymentfor the physician's services for an eye exam. You say that since this is a Medicare-covered eye exam, you should not have any financial responsibility.The Plan denied your request. The Plan says the cost-share 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 $25 copayment for vision care, Medicare-covered exams.You have been asked to pay a $25 copayment for the physician's services for an eye exam. The physician's services for an eye exam falls within the vision 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 the Plan.Therefore, we decided that the Plan does not have waive the copaymentfor physician's services for an eye examprovidedon July 29, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve gingival irrigation (D4921) for the lower left and lower
right quadrants.
You asked the Plan to pre-approve the gingival irrigation. The Plan denied your request. The Plan says gingival
irrigation 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, gingival irrigation is not among those
covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve gingival irrigation
(D4921) for the lower left and lower right quadrants.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on August 13, 2019 by out of network provider.
You asked the Plan to pay for physician services. You say that these services are provided in good faith. You say that you would like this claim to be approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained for these services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. 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 an office visit provided on August 13, 2019 by out of network provider.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for the imaging services (73523) provided on July 26, 2019.
You asked the Plan to pay for the imaging services. You say that you would like the plan to reconsider their denial of payment. The Plan denied your request. The Plan says that a medical review cannot be conducted until the Plan receives the requested corrected claim.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the 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. Specifically, the Plan did not provide enough documentation to support their reason for denial based on Medicare payment guidelines. A complete case file, per Medicare guidelines includes all documentation used to support the Plan's denial. The case file does not include any supporting documentation to demonstrate that Medicare payment guidelines were not met. We are unable to determine if the Plan reviewed the correct claim in dispute based on the lack of documentation provided by the Plan. Therefore, we decided that the Plan has to pay for the imaging services (73523) provided on July 26, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the maxillary partial denture.
You asked the Plan to pre-approve the maxillary partial denture. You say that you are not able to eat and need the denture now. The Plan denied your request. The Plan says this service exceeds the benefit allowance. The Plan also says that this service is allowed one time every 60 months.
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, dentures are limited to one set every five (5) years. The record shows that you received a denture on June 29, 2017 and your dentures benefit is now exhausted. Therefore, we decided that the Plan does not have to pre-approve the maxillary partial denture.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on May 7, 2018.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says under Medicare guidelines Original or Traditional Medicare is still responsible for payment till the start of the next month after revocation.
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 May 3, 2018. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for physician's services provided on May 7, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by out of network provider.You asked the Plan to pre-approve the referral. You say that you would like to continue seeing the physician because you trust him with your care. The Plan denied your request. The Plan says you must get care from a network provider and thereis a preferred provider in-network.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 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. 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 medical services to be provided by out of network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Stelara
You asked the Plan to pre-approve Stelara. You say that the enrollee has tried and failed other medications. The
Plan denied your request. The Plan says Stelara to be administered at home is not covered under the Part B
benefit.
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 Stelara
Benefits for Stelara 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe core build-ups (D2950) provided on July11, 2019 and August 19, 2019.You asked the Plan to pay forthe core build-ups (D2950). You say that since have coverage for crowns, core build-ups should also be covered. The Plan denied your request. The Plan says the services are not covered benefits.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 core build-ups (D2950) are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay forthe core build-ups (D2950) provided on July 11, 2019 and August 19, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa injection for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says step therapy guidelines were not followed.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the injection. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the provided medical records do not indicate that the enrollee has tried and failed Orthovisc and Monovisc. It is not indicated 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 the injection have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa injection for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe repair of a seat elevation system for your power wheelchair.You asked the Plan to pre-approvethe requested repair. The Plan denied your request. The Plan says a seat lift does not serve a medical purpose.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal, the power seat elevation feature,does not serve a purpose that is primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approvethe repair of a seat elevation system for your power wheelchair.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory work provided on September 3, 2019.
You asked the Plan to waive the copayment for the laboratory work. You say that there are no doctor's offices that have an in-office lab facility to process your blood-work. You should be charged a $0 copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for in-network Medicare-covered lab services. You have been asked to pay a $40 copayment for the laboratory work. The laboratory work falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" 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 laboratory work provided on September 3, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forpercutaneous transluminal mechanical thrombectomy, vein(s), including intraprocedural pharmacological thrombolytic injections and fluoroscopic guidance (37187) provide February 2, 2019.You asked the Plan to pay forcode 37187. You say that the service provided was medically necessary.The Plan denied your request. The Plan says the billed code is not supported.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.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 code 37187. Our reviewer says that code 37187 is not supported by the medical records. Our physician reviewer found the medical documentation submitted does not include documentation of a Percutaneous transluminal mechanical thrombectomy, vein(s), including intraprocedural pharmacological thrombolytic injections and fluoroscopic guidance. The operative note did not support that this procedure was performed.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of code 37187 have not been met. Therefore, we decided that the Plan does not have to pay forpercutaneous transluminal mechanical thrombectomy, vein(s), including intraprocedural pharmacological thrombolytic injections and fluoroscopic guidance (37187) provide February 2, 2019.