Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveprivate duty nursing.You asked the Plan to pre-approvethe requested services. You say that the enrollee requires 24-hour care.The Plan denied your request. The Plan says coverage criteria has not been met. Skilled home health services and home health aide services could be covered, if requested.Medicare generally does not cover private duty nursingservices. However, the Plan offers a private duty nursingbenefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.We askedour 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 requested services. Our physician reviewer found that the enrollee has a relevantpast medical history that includes a traumatic brain injury due to near drowning, scoliosis, and seizures. He has an anoxic brain injury and is on a ventilator while sleeping. He has a feeding tube and multiple muscle contractures. He is at a dependent level of function and is nonverbal. He has incontinence of bowel and bladder and has frequent seizures. Recent treatments include an infusion for osteopenia. He is receiving chest physical therapy 3 times per day and nebulizer treatments and passive range ofmotion 3-4 times per day to prevent contractures. He has severe scoliosis. The medical information supports that the enrollee is homebound. He has multiple comorbid conditions that require periodic skilled nursing oversight of his condition. However, he does not require continuous 24-hour care. His care can be appropriately provided by his nonskilled caregivers with skilled nursing oversight as needed. The number of service hours requested is not appropriate for the enrollee's condition.We looked at thisphysician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approveprivate duty nursing.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve gel arm pads for the enrollee.You asked the Plan to pre-approve gel arm pads. The Plan denied your request. The Plan says that durable medical equipment is not covered in a SNF.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home. Records show that gel arm pads is being requested for use in a SNF or hospital.Therefore, we decided that the Plan does not have to pre-approve gel arm pads for the enrollee
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forknee orthosis (L1833), lumbar-sacral orthosis (L0650) and suspension sleeve (L2397) provided to the enrollee from September 9, 2019 through September 12, 2019.You asked the Plan to pay forthe orthoses and sleeves. You say that the durable medical equipment is medically necessary.The Plan denied your request. The Plan says the services are not supported.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 orthoses and sleeves. Our reviewer says that the orthoses and sleeve ordered. Our physician reviewer found the documentation in the case file does not support that the requested knee orthosis and sleeve were medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. There is no documentation of recentinjury to, or recent surgical procedure on, the enrollee's knee, and there is insufficient credible objective documentation of joint laxity. The item coded L2397 (sleeve) is not separately payable when the base item is not covered.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 orthoses and sleeves have not been met.Therefore, we decided that the Plan does not have to pay forknee orthosis (L1833), lumbar-sacral orthosis (L0650) and suspension sleeve (L2397) provided to the enrollee from September 9, 2019 through September 12, 2019
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vascepa for the enrollee.
You asked the Plan to pre-approve Vascepa. You say that the enrollee has tried and failed Rosuvastatin. The Plan denied your request. The Plan says the enrollee's medical plan does not cover outpatient prescription 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 Vascepa for the enrollee.
Benefits for Vascepa 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897).
You asked the Plan to pre-approve Prolia. You say that the Prolia is medically necessary for the treatment of
the member's condition. The Plan denied your request. The Plan says the member does not have a history of
osteoporotic fracture and does not meet the step therapy exception criteria.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve Prolia. Our reviewer says that the
member has not tried and failed a trial of zoledronic acid. There is no documentation provided indicating that
the Plan's required drug is likely to be less effective and/or likely have adverse effects for the enrollee. Our
physician reviewer found the record does not show the member has a history of osteoporotic fracture.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to
pre-approve Prolia (J0897).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that remaining in the current setting presents a risk of readmission and deterioration. The Plan denied your request. The Plan says the member is receiving appropriate in-patient acute care and does not require transfer to a LTACH.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the member is not stable for transfer to any other location at this time and although prolonged hospitalizations increase risk for new issues, transfer when unstable is riskier. The proposed treatments at the LTACH are not materially different than what is already being provided currently and would equally be appropriate and covered. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Blepharoptosis repair.You asked the Plan to pre-approve the Blepharoptosis repair. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says there is insufficient documentation as there were no photos submitted with this request.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 Blepharoptosis repair. Our reviewer says that the medical records are insufficient to support the procedure. Our physician reviewer found the record does not include sufficient documentation to determine the visual field loss and potential correction.We looked at this physician's review, the file, and Medicare rules. Based onthis information, we decided that Medicare rules for coverage of the Blepharoptosis repair have not been met. Therefore, we decided that the Plan does not have to pre-approve Blepharoptosis repair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for determination of refractive state (CPT Code 92015) performed on July 29, 2019.You asked the Plan to pay for the eye refraction. You say that you are appealing for reconsideration of the denied charges.The Plan denied your request. The Plan says you were seen for a medical reason/diagnosis, this is not a covered benefit if not performed as routine. The Plan states eye refractions are only covered by your plan if performed by a participating provider and performed as a routine screening.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The provider states you were seen for a medical reason, not as routine. Eye refractions are only covered by your plan if performed by a participating provider and performed as a routine screening. 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 pay for determination of refractive state (CPT Code 92015) performed on July 29, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services on October 10, 2019, purchased atan out-of-network provider.You asked the Plan to pay forthe services. You say that you are requesting additional reimbursement of services rendered.The Plan denied your request. The Plan says the plan states they have reimbursed you the maximum reimbursement per your benefit in your EOC.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. 
We looked at the file and the Plan's rules.According to the plan, sales tax of $13.78 and lens processing fee $10.00 is not a covered benefit and you will not be reimbursed for this. A check was sent to you by the plan for $180.00.Therefore, we decided that the Plan does not have to pay forthe services on October 10, 2019, purchased at an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for Computed Tomography (CT) of the thorax (71260) provided June 15, 2019.
You asked the Plan to pay for the CT scan. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim is a duplicate of a previously submitted claim.
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 find that CPT code 71260 is not supported in the medical record. Specifically, the claim at issue is a duplicate of claim 19H101028300 which was already paid. Based on this information, we decided that Medicare rules for coverage of the CT scan have not been met. Therefore, we decided that the Plan does not have to pay for Computed Tomography (CT) of the thorax (71260) provided June 15, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), the bitewing x-rays (D0274), the periapical x-ray, initial (D0220), the 3 additional periapical x-rays (D0230), and the panoramic x-ray (D0330) provided on July 10, 2019.You asked the Plan to pay forthe dental services. You say that you were misinformed about the provider's participating status with the Plan.The Plan denied your request. The Plan says dental services received out of network are not covered. The Plan also says that the provider in this case is not a 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 dental services that you received are not covered when you receive the services out of network.Therefore, we decided that the Plan does not have to pay forthe periodic oral evaluation (D0120), the bitewing x-rays(D0274), the periapical x-ray, initial (D0220), the 3 additional periapical x-rays (D0230), and the panoramic x-ray (D0330) provided on July 10, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from August 29, 2019 to August 30, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the acute inpatient hospital care was medically necessary. The Plan denied your request. The Plan says the patient did not meet criteria for coverage of acute inpatient hospital care.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the case file contains no emergency room (ED) documentation nor a history & physical examination. There is no documentation of medical decision-making. Additionally, without pertinent medical records, the documentation does not show that, at the time of inpatient admission, it was reasonable for the admitting physician to expect that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from August 29, 2019 to August 30, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided on October 7, 2019.
You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that you were told that you would not owe anything for Medicare Part B drugs. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 20% coinsurance for Medicare Part B prescription drugs. You received Medicare Part B drugs on October 7, 2019. The total allowed amount is $1,095.36 and 20% of that is $219.08. You have been asked to pay the total coinsurance amount of $219.08 for Medicare Part B drugs. Medicare Part B drugs fall within the Medicare Part B prescription drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided on October 7, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the sinus perforation repair (D7261) provided on August 22,
2019.
You asked the Plan to pay for the dental service. You say that you had a tooth extracted. You say that the
provider perforated your sinus cavity which required an additional procedure to correct. You say that it is
unethical for this provider to have caused you harm and then to demand payment to repair the damage that was
done. You also say that the service was more medical in nature than dental and should be processed that way.
The Plan denied your request. The Plan says the annual maximum of $1,000 for comprehensive dental care has
been exceeded.
Medicare generally does not cover dental services. The Plan follows the same rule.
The service you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid
for by Medicare.
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 annual maximum for
comprehensive dental care has been exceeded.
Date of Service Claim # Plan Paid
5/1/2019 $86.50
7/9/2019 $48.00
7/23/2019 $700.50
8/1/2019 $37
8/6/2019 $13
8/22/2019 $115
TOTAL: $1,000
Therefore, we decided that the Plan does not have to pay for the sinus perforation repair (D7261) provided on
August 22, 2019.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for the ambulance services provided on March 10, 2019.
You asked the Plan to pay for the ambulance services. You say that the Plan should pay this claim. The Plan denied your request. The Plan says that the secondary diagnosis was missing from the claim.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The only claim in the case file has the secondary diagnosis code. Based on this information, we decided that Medicare rules for coverage of the ambulance services have been met. Therefore, we decided that the Plan has to pay for the ambulance services provided on March 10, 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee form August 2, 2019 to August 3, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that this is medically necessary. The Plan denied your request. The Plan says the information received does not support an acute inpatient stay.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee form August 2, 2019 to August 3, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from April 12, 2019
through April 14, 2019.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you are appealing your
cost-share responsibility for the services you received. 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).
Review of the file shows that you were admitted on April 12, 2019 and discharged on April 14, 2019. You
were asked to pay a $225 copayment per day from April 12, 2019 through April 13, 2019, days 1-2 of your
inpatient hospital care. You were discharged on April 14, 2019 and there was no copayment charge for the day
of discharge. Per your contract there is a $225 copayment per day required for days 1-5. 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 hospital care from April 12, 2019 through April 14, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an osteogenesis stimulator, electrical, non-invasive, spinal applications to be provided by an out of network provider.
You asked the Plan to pre-approve an osteogenesis stimulator. You say that your surgeon referred you to Orthofix. The Plan denied your request. The Plan says there are participating providers that can supply this requested item.
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 an osteogenesis stimulator, electrical, non-invasive, spinal applications to be provided by an out of network provider.