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

We decided that the Plan does not have to provide a Flexitouch pneumatic compression device and appliances
You asked the Plan to provide a pneumatic compression device (E0652) and appliances (E0667). You say that the basic pump was tried once and discontinued as it provided no clinical improvement. The Plan denied your request. The Plan says the enrollee has not had a four-week trial with a basic compression device.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily,
multiple-hour home usage of the E0650 or E0651 is required. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to provide a Flexitouch pneumatic compression device and appliances
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea pneumatic compression device (E0652) and segmental pneumatic appliance/garments (E0667).You asked the Plan to pre-approvea pneumatic compression device and garments. You say that you are requesting an appeal regarding denial of coverage. You understand coverage was denied as not medically necessary and you respectfully disagree.The Plan denied your request. The Plan says you have not had a failed four week trail of either E0650 or E0651.The Plan follows Medicare rules. The rules state that a PCD coded as E0652is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.Therefore, we decided that the Plan does not have to pre-approvea pneumatic compression device (E0652) and segmental pneumatic appliance/garments (E0667).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided to the enrollee on April 30, 2019.You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order/lab requisition or medical records stating exactly what tests are to be performed.The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met.Therefore, we decided that the Plan does not have to pay for the drug testing services provided to the enrollee on April 30, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe skilled nursing services provided from August 5, 2019 to August 25, 2019.You asked thePlan to pay forthe 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 the enrollee did not have daily skilled nursing or rehabilitation needs that required an inpatient stay at a SNF.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 pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 the skilled nursing services have not been met.Therefore, we decided that the Plan does not have to pay forthe skilled nursing services provided from August 5, 2019 to August 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 for the ambulance services. You say that you were in a diabetic coma and your husband was trying to revive you when the paramedics arrived. You say that they treated you and finally brought your blood sugar levels back up. The paramedics asked if you wanted to be transported to the hospital and you decided not to since you were recovered at that point. You say that the services were medically necessary as you would have been dead if the paramedics had not revived you.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 12, 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on August 6, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plandenied 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 forthe drug testing rendered on August 6, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown.You asked the Plan to pre-approve the crown. You say that the Plan's benefit material is not clear. You also say that you called and tried to get confirmation regarding if a crown was covered and could not get a straight answer.The Plan denied your request. The Plan says this service is not included on your benefit plan and 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 Plan only covers restorative services that include amalgam fillings and anterior composite resin fillings.Therefore, we decided that the Plan does not have to pre-approve a crown.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper denture (D5110), and a complete lower denture (D5120).You asked the Plan to pre-approvethe dental services. You say that you want dentures. You say that you choke on food. You also say that you have severe Crohn's disease.The Plan denied your request. The Plan says dentures are covered once every 5 years. The Plan also says that the frequency limit has been reached.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 and dentures are a covered service, the frequency limit has been reached. The record shows the Plan paid for the dentures you received on June 12, 2017.Therefore, we decided that the Plan does not have to pre-approvea complete upper denture (D5110), and a complete lower denture (D5120).
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 IRF services are medically necessary.The Plan denied your request. The Plan says the enrollee's needs can be met a lower level of care.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 patient may benefit and participate in additional therapy of PT and OT but the patient does not require this on an intensive rehabilitation facility therapy program level in an IRF. Services can be provided at a lower level of care.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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forparenteral nutrition supplies (B4185, B4197, B4220, and B4224) provided from June 20, 2019 to June 26, 2019.You asked the Plan to pay forparenteral nutrition supplies. You say that these items were medically necessary.The Plan denied your request. The Plan says the submitted records do not contain a valid proof of delivery.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The delivery ticket does not have a carrier tracking number and a proof of delivery was not submitted.Therefore, we decided that the Plan does not have to pay forparenteral nutrition supplies (B4185, B4197, B4220, and B4224) provided from June 20, 2019 to June 26, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to agree to pay 10% more fora pontic and retainer crown.You asked the Plan to agree to pay 10% more for the pontic and retainer crown. You say that you were originally told that these services were covered. You also say that you feel the Plan should cover 10% more because of all of the time you spent making calls to have this corrected.The Plan denied your request. The Plan says pontic and retainer crown are restorative services. The Plan also says that these services are covered but are only reimbursed at 50% if they are provided by an in-network provider.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 ANOC clearly states that you are responsible for 50% coinsurance of the total cost for restorative services.Therefore, we decided that the Plan does not have to agree to pay 10% more fora pontic and retainer crown.Your complaint about being treated unfairly by the Plan 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered to enrollee on May 8, 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 enrollee on May 8, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a reduction mammaplasty (19318).
You asked the Plan to pre-approve a reduction mammaplasty (19318). You say that the requested reduction mammaplasty is medically necessary. The Plan denied your request. The Plan says the requested reduction mammaplasty is not medically necessary.
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 a reduction mammaplasty (19318). Our reviewer says that the requested reduction mammaplasty is not medically necessary. Our physician reviewer found medical documentation from 2/4/20 noted that the enrollee complained of large breasts. She states that she does not have a lot of neck pain, shoulder pain, or rashes but just is unhappy with the size of her breasts. Breast exam notes that the right breast is slightly larger than the left breast. She has dense breasts. She has no shoulder grooving. Plan was for bilateral breast reduction with an approximately 300-350 gram reduction. Additional documentation from 2/14/20 noted that the enrollee has to wear double bras, there are grooves in the shoulders at the end of the day, and that when she lays flat she feels like the breasts are choking her. Based on the medical documentation provided, there is not a clear clinical scenario of symptomatic macromastia that would likely improve with breast reduction. The surgeon's documentation does not support that there is a significant functional impairment related to macromastia. The surgeon does not adequately define the level of macromastia and photographs were not provided for review. Based on the documentation provided, the enrollee does not have clear functional impairment directly related to macromastia that has failed reasonable conservative management. The requesting surgeon has not adequately defined the level of macromastia, as well as clear typical symptoms related to any macromastia. Therefore, bilateral breast reduction does not satisfy Medicare medically necessary criteria. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a reduction mammaplasty (19318) have not been met. Therefore, we decided that the Plan does not have to pre-approve a reduction mammaplasty (19318).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the implant supported porcelain/ceramic crown on tooth #5 provided on October 8, 2019.You asked the Plan to pay forthe implant supported porcelain/ceramic crown. You say that you recently had a broken tooth removed. You also say that the area was prepared for an implant and then a crown.The Plan denied your request. The Plan says implant benefits are limited to anterior (front) teeth. The Plan also saysthat anterior (front) teeth include teeth numbered 6 to 11 and 22 to 27.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, implant services are only covered for anterior (front) teeth. The record shows that you received an implant supported porcelain/ceramic crown on tooth #5. Tooth #5 is a posterior (back) tooth.Therefore, we decided that the Plan does not have to pay forthe implant supported porcelain/ceramic crown on tooth #5 provided on October 8, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Retacrit.
You asked the Plan to pre-approve the Retacrit. You say that the enrollee has anemia and chronic kidney
disease. You say that the records provided support the criteria for coverage of the requested drug have been
met. You say that the drug being requested would be dispensed to the patient by a retail pharmacy. The Plan
denied your request. The Plan says the request does not meet the criteria for coverage under the enrollee's Part
B benefit.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B,
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be
brought to the office for administration. Since the medication does not represent an expense to the physician
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that
the Plan does not have to pre-approve Retacrit under the Part B benefits.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Avonex.You asked the Plan to pre-approve Avonex. You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says Avonex 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-approveAvonex.Benefits for Avonexmay 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: 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-approveIRF care. You say that this is necessary for the enrollee to return to her prior level of function.The Plan denied your request. The Plan says the enrollee's needs could be met in another setting.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonableand 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 records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a skilled nursing facility level of care. In regards to the enrollee's therapy needs, a less intensive, longer duration of therapy will allow for measurable gains to be attained within a predicted period.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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvesurgical extractions (D7210) for teeth #  20, 21, 22, 23, 24, 25, 26, 27, 28 and 29, the initial 15 minutes of general anesthesia (D9222), and 3 additional 15 minutes of general anesthesia (D9223).You asked the Plan to pre-approvethe dental services. You say that the enrollee has a gross infection. You say that the enrollee will not be able to tolerate the surgical extractions without the general anesthesia.The Plan denied your request. The Plan says the annual maximum of $2,000 for dental service has been reached.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 thePlan offers a dental benefit in excess of Medicare coverage, the annual maximum of $2,000 has been reached for the year.Date of ServiceClaim NumberPlan Paid1/8/2019200096339500$1,7431/13/2019200143396600$551/20/2019200210361500$$202TOTAL:$2,000Therefore, we decided that the Plan does not have to pre-approvesurgical extractions (D7210) for teeth #  20, 21, 22, 23, 24, 25, 26, 27, 28 and 29, the initial 15 minutes of general anesthesia (D9222), and 3 additional 15 minutes of generalanesthesia (D9223).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foran office visit provided on August 30, 2019 to September 23, 2019 by an out of network (OON) provider.You asked the Plan to pay foran office visit. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says no prior authorization was obtained for these services. The Plan says that there are 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 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 Plandid 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 foran office visit provided on August 30, 2019 to September 23,2019 by an out of network (OON) provider.