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

We decided that the Plan does not have to pay for hearing aids purchased on September 14, 2019 from an out-of-network provider.
You asked the Plan to pay for the hearing aids. You say that you did not want to go through the plan and pay
$3000 when you paid $1750 at the facility. You state it does not say anywhere that you must use the Plan's
provider to get the benefit. The Plan denied your request. The Plan says there is no coverage if hearing aids or
related services are received from an out-of-network provider. The Plan states hearing aids are covered when
purchased from the Plan's provider.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case.
Review of the file show that you purchased hearing aids on September 14, 2019 from an out-of-network
provider. Your EOC clearly states, there is no coverage if hearing aids or related services are received from an
out-of-network provider. Therefore, we decided that the Plan does not have to pay for hearing aids purchased
on September 14, 2019 from an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve osseous surgeries (D4260).
You asked the Plan to pre-approve the osseous surgeries. You say that before signing up for this plan you were
told multiple times that your periodontal services would be covered by your in-network provider. You also say
that before enrolling you were not shown the Evidence of Coverage and that your preventive surgery would not
be covered. The Plan denied your request. The Plan says this service is not covered under your 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 pre-approve
osseous surgeries (D4260).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a rental automatic external defibrillator (K0606RR) provided on October 4, 2019. You asked the Plan to waive the coinsurance for the DME. You say that you only used the item for three (3) days in October and returned the item. You state you do not feel that you should be responsible for the cost-share for the entire month. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). According to Medicare HCPCS Code K0606 (life vest) is considered a capped rental item, meaning that they are paid per month for the item. This means that if you have the life vest for any amount of time within that month, then the practice has the right to bill for entire month. Per your 2019 EOC, you have a 20% coinsurance for Medicare-covered DME. You did use the device for 3 days in October 2019, and there is no daily rental rate for this device. Therefore, the claim was processed with the correct cost share of $579.90. 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 a rental automatic external defibrillator (K0606RR) provided on October 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional home health services.
You asked the Plan to pre-approve additional home health services. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. 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 additional home health services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the services requested must be reasonable and necessary to the treatment of your illness or injury. The documentation reveals that you have a home health aide 2 times weekly in conjunction with your skilled therapy and nursing services. The documentation does not reveal extenuating factors that would require additional home health services. Your requested care is considered custodial and not necessary to treat your illness. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve additional home health services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are 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 services are not medically necessary. Our physician reviewer found the records show that you are currently at home and were hospitalized in January of 2020 with a transient ischemic attack (TIA). You have muscle weakness and have been improving with home physical therapy. You need minimal assistance for transfers, activities of daily living, dressing, bed mobility, and ambulation. You have no complex needs that require an acute hospitalinpatient stay with an interdisciplinary approach to rehabilitation care. You may benefit from further therapy but do not require an intensive therapy program 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found this enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF. This enrollee's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment. The enrollee does not require these skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis". As a practical matter this enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the requested admission to an IRF is medically necessary.The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.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 rulesto determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested admission to an IRF does not meet criteria. Our physician reviewer found the member was admitted for acute care on 03/14/2020 and underwent intramedullary nailing of a right hip intertrochanteric femur fracture. Her relevant past medical history includes atrial fibrillation, diabetes, hypertension, and asthma. The member lives alone in a single level residence with 15 steps to the entrance and had been independent. DME includes a walker and bedside commode. She is weightbearing as tolerated. On 03/18/2020 she required minimal assistance for transfers and ambulating 20 feet with a rolling walker. She required minimal assistance for bathing and was dependent for lower body dressing. As of 03/19/2020 she required moderate/minimal assistance for transfers and was now ambulating 150 feet with a rolling walker and minimal assistance. The member is status-post right hip fracture treated with intramedullary nail nailing without reported postoperative complication as described above. The member's medical conditions appear stable. There are no complex wound care needs. There are no unaddressed medical issues. She does not require medical oversightof her condition at an acute hospital level of care. The member requires physical therapy for mobility and occupational therapy for remaining activities of daily living and adaptive equipment. She is ambulating greater than household distances and does not require an intensive rehabilitation therapy program. The member's medical conditions appear stable and she is participating in the treatments being provided. She had been able to function at an independent level and would be expected to be able to fully participate and benefit from the required intensity of an acute rehabilitation therapy program. There is no reason to think that an intensive rehabilitation therapy program would significantly impact the member's condition differently compared with therapyprovided at a less intense level.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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a male vacuum erection system.
You asked the Plan to pre-approve a vacuum erection device (L7900). You say that because of a medical
condition the enrollee needs a male vacuum erection system The Plan denied your request. The Plan says male
vacuum erection systems are not covered by Medicare or the Plan.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of a vacuum erection device (L7900) have not been met. Therefore, we decided that the Plan does not
have to pre-approve a male vacuum erection system.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation to be provided.You asked the Plan to pre-approve the consultation to be provided. You say that you want a second opinion consultation forhip pain since you know there is a problem andyou want to see a provider. You say that you are not happy withthe in-network provider because the provider did not examine you completely or view your x-ray results. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.The requested provider in this case is not a network providerwith the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approvea consultation to be provided
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the rehab needs are not complex, and an interdisciplinary approach is not required.
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 the patient'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 patient's medical status requires the intensity of an IRF stay with close physician or nursing supervision. The patient may benefit and participate in additional therapy of PT and OT but the patient's functional level does not require this on an intensive rehabilitation facility therapy program level 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-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial upper denture (D5213).You asked the Plan to pre-approve the dental item. You say that you have medical issues and feel they will worsen if you do not receive the partial denture. You also say that you get sick easily.The Plan denied your request. The Plan says partial dentures are 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 partial denture is not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approve a partial upper denture (D5213).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient care provided May 30 to June 2, 2019.
You asked the Plan to waive the copayment for the inpatient services. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct cost sharing was applied.
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 $395 per day copayment for days 1 through 4 of each admission for Inpatient Hospital Care. You have been asked to pay a $790 copayment for 2 days of inpatient hospital care. 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 inpatient care provided May 30 to June 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic radiology and chemistry procedures provided on
November 11, 2019.
You asked the Plan to pay for the diagnostic radiology and chemistry procedures. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
The requested provider in this case is not a network provider with the Plan. 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 diagnostic radiology and chemistry procedures provided on November 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve FreeStyle Libre Continuous Glucose Monitoring
sensors.
You asked the Plan to pre-approve CGM sensors. You say that the Evidence of Coverage never said there was
qualifying conditions. The Plan denied your request. The Plan says you are not insulin injecting three or more
times a day or testing four or more times a day.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they
are medically reasonable and necessary and replace a blood glucose monitor.
We looked at the file and Medicare rules. The record shows you are not insulin treated three or more times a
day and there is no test log. Based on this information, we decided that Medicare rules for coverage of CGM
sensors have not been met. Therefore, we decided that the Plan does not have to pre-approve FreeStyle Libre
Continuous Glucose Monitoring sensors.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the prosthetic services to be provided by an out of network provider.
You asked the Plan to pre-approve the prosthetic services with an out of network provider. You say that you were advised you would be able to use this provider when needed for your prosthetics. The Plan denied your request. The Plan says prosthetic services can be obtained 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 care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the prosthetic services to be provided by an out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the ophthalmology services provided on February 18, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the ophthalmology services. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. The plan says that non-emergent services with non-contracted providers require prior-authorization prior to services being rendered.
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 the ophthalmology services provided on February 18, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided from October 29, 2019 to October 30, 2019.
You asked the Plan to pay for these drugs. The Plan denied your request. The Plan says that these are not 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 pay for the self-administered drugs provided from October 29, 2019 to October 30, 2019.
Benefits for these 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.