Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forinpatient psychiatric services from March 30, 2020, to April 1, 2020.You asked the Plan to pay forinpatient psychiatric services from March 30, 2020, to April 1, 2020.You say that the inpatient services were medically necessary.The Plan denied your request. The Plan says they will approve the first four days but the last two inpatient psychiatric service days were not medically necessary.The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules todetermine if the Plan was correct in denying the request to pay for inpatient psychiatric services from March 30, 2020, to April 1, 2020. Our reviewer says that the services were not medically necessary. Our physician reviewer found based upon review the records provided it was not expected this enrollee would improve in a reasonable period of time beyond the dates in question as the enrolleewas not showing any dangerousness to selfor others, no auditory or visual hallucinations and no abnormal behaviors. This enrolleewas compliant with treatment. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as the enrolleedid not have any suicidal or homicidal thoughts, hallucinations or aggressive behaviors. The health plan's denial of continued inpatient psychiatric services appears appropriate. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric services from March 30, 2020, to April 1, 2020have not been met.Therefore, we decided that the Plan does not have to pay forinpatient psychiatric services from March 30, 2020, to April 1, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $250 copayment charged for ambulance transport 
provided on April 4, 2020. 
 
You asked the Plan to waive this transport. You say that you do not believe this copayment is correct. The Plan 
denied your request. The Plan says this copayment was charged based on the service provided and the Plan 
contract agreement. 
 
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 $250 
copayment for ambulance transport. 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 $250 copayment charged for ambulance 
transport provided on April 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 2 fillings (D2335) provided on July 21, 2020. 
 
You asked the Plan to pay for the dental services. You say that the services should be paid. The Plan denied 
your request. The Plan says 2 fillings are covered per calendar year. The Plan says that the frequency limit has 
been exceeded. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage and fillings are a covered service, the 
frequency limit of 2 per calendar year has been exceeded. The record shows that the Plan paid for 2 fillings that 
you received on February 3, 2020, thus exhausting this benefit. Therefore, we decided that the Plan does not 
have to pay for the 2 fillings (D2335) provided on July 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided. 
 
You asked the Plan to pay for the subsequent nursing facility care. 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 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 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 subsequent nursing facility care provided.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve physical therapy. You say that you do not drive and want to be close to your 
house. The Plan denied your request. The Plan says there are in-network providers available. 
 
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 
physical therapy to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the enrollee is a cutely ill and LTACH care is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet the requirements for coverage of LTACH care. The Plan says that the enrollee's care can beprovided in the current inpatient hospital.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 enrollee was admitted to the current acute care hospital with respiratory failure, sepsis, pneumonia related to COVID-19. He was treated with IV antibiotics, Decadron, supplemental oxygen, but was later intubated due to worsening. He underwent tracheostomy, is getting tube feeds, and was started on Cardizem IV due to SVT. Ventilation weaning has been initiated but failed thus far. He still has leukocytosis and episodes of SVT. The enrollee appears to be unstable at this time, requiring additional short-term acute care services which can be received in the current setting. The enrollee does not require services at the LTACH that are not already available at the current hospital. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current hospital. Therefore, this request for LTACH services will be considered not medically necessary. Transfer may be considered when the enrollee is stable and long-term prognosis is clearer.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-approvelong term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that these were covered prior to your switch to Medicare. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on 
June 18, 2020. 
 
You asked the Plan to pay for out of network services. You say that this claim should be paid. The Plan denied 
your request. The Plan says the enrollee did not have a referral or prior authorization for out of network care. 
 
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 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 out of network physician 
services provided to the enrollee on June 18, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided from June 16, 2020, to June 
30, 2020 by an OON provider. 
 
You asked the Plan to pay for the medical services. You say that the enrollee contacted the Plan to request a 
prior authorization, and was told that a prior authorization was not needed for therapy services. The Plan denied 
your request. The Plan says the services were rendered by a non-participating provider. The Plan also says that 
prior authorization was not obtained. 
 
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 medical services provided from June 16, 2020, 
to June 30, 2020 by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve wheelchair transit option, seat pouch, or push handles. 
 
You asked the Plan to pre-approve the wheelchair transit option, seat pouch, push handles. You say that the 
enrollee needs a wheelchair and accessories. The Plan denied your request. The Plan says a transit option is for 
outside the home and the seat pouch and push handles do 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 transit option is not covered as neither Medicare nor the Plan cover equipment for use outside the home. 
The pouches and push handles do not serve a purpose that is primarily medical in nature. These items are 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a wheelchair transit option, seat pouch, or push handles.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve Laparoscopy. 
 
You asked the Plan to pre-approve Laparoscopy, surgical, with total hysterectomy (58571). You say that this 
procedure is medically necessary for this enrollee due to pelvic organ prolapse that is affecting the enrollee's 
quality of life. The Plan denied your request. The Plan says that the procedure is not medically necessary for a 
grade 1 uterine prolapse. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Laparoscopy, surgical, with total 
hysterectomy, for uterus 250g or less. (58571). Our reviewer says that the requested procedure is considered 
medically reasonable and necessary in this case. Our physician reviewer found treatment of patients with 
uterovaginal prolapse, which reasonably includes surgical management, is indicated for women with symptoms 
of prolapse (which this enrollee has) or associated conditions such as urinary, bowel, or sexual dysfunction 
(which this enrollee also has). Surgical candidates include women with symptomatic prolapse who fail or 
decline conservative management of their prolapse. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less. (58571) 
have been met. Therefore, we decided that the Plan has to pre-approve Laparoscopy.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator. 
 
You asked the Plan to pre-approve these services. You say that you would like to be able to move without 
having to carry the heavier tanks. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. The rules state that for equipment to be covered, it must be appropriate and needed 
for use inside the home. 
 
The file shows that you have a stationary oxygen concentrator and Homefill system. This equipment serves the 
same purpose as the requested portable oxygen tank. Furthermore, Medicare does not cover DME for use 
outside of the home. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen 
concentrator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve RevoFit adjustable closures (L5999). 
 
You asked the Plan to pre-approve RevoFit adjustable closures (L5999). You say that the requested items are 
medically necessary. The Plan denied your request. The Plan says rules for pre-approval have not been met. 
 
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 RevoFit adjustable closures (L5999). 
Our reviewer says that the requested items are not reasonable and necessary for the diagnosis or treatment of an 
illness or injury or to improve the functioning of a malformed body member. Our physician reviewer found that 
the medical records provided do not meet the requirements listed in the Social Security Act, Section 1862 
(a)1(A) and the 42 CFR 411.15(k) for Medicare coverage for RevoFit adjustable closures (L5999) to 
accommodate the enrollee's bulbous distal limb shape. The recent treating medical practitioner note on 
November 12, 2020, does not reveal bulbous deformities or deformities that require this adjustable closure 
feature. The request appears to exceed the enrollee's medical need. A review of the RevoFit adjustable closure 
in the literature does not indicate that there is sufficient long term evidence of effectiveness for the use of this 
device or that this is the standard of care in prosthetic management fitting. At this time the requested Revofit is 
not proven to be more beneficial for treatment of the enrollee's medical condition/function than any available 
standard treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of RevoFit adjustable closures (L5999) have not been met. Therefore, we decided 
that the Plan does not have to pre-approve RevoFit adjustable closures (L5999).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided on July 14, 2020. 
 
You asked the Plan to pay for this service. You say that this service should be covered by the Plan. The Plan 
denied your request. The Plan says the services provided are not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not 
manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for chiropractic 
services provided on July 14, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CTA of the chest (71275) and a CTA of the abdomen 
(74175). 
 
You asked the Plan to pre-approve a CTA of the chest and a CTA of the abdomen. You say that the requested 
CTA of the chest and CTA of the abdomen are medically necessary. The Plan denied your request. The Plan 
says there was not enough information sent to be able to make a medical necessity decision based on Medicare 
criteria. 
 
The Plan must follow Medicare rules. The rules say for Medicare to consider coverage and payment for any 
item or service, the information submitted by the supplier or provider must corroborate the documentation in 
the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. In this 
case, the Plan made multiple attempts to obtain medical records from you with no response. Therefore, we 
decided that the Plan does not have to pre-approve a CTA of the chest (71275) and a CTA of the abdomen 
(74175).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the filling or pins placed when preparing a tooth for a 
crown (D2950). 
 
You asked the Plan to pre-approve the filling or pins placed when preparing a tooth for a crown. You say that 
you would like this service covered under your supplemental dental benefit. The Plan denied your request. The 
Plan says the rules coverage criteria have not been met. 
 
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. The Plan covers the filling or 
pins placed when preparing a tooth for a crown when the services are medically necessary and reasonable.  
 
We looked at the the file and Medicare rules. The information we have indicates that the service that will be 
performed, the filling or pins placed when preparing a tooth for a crown, will not be performed together with a 
crown but will be to repair an existing crown. Based on this information, we decided that the Plan's rules for 
coverage of the filling or pins placed when preparing a tooth for a crown have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the filling or pins placed when preparing a tooth for a crown 
(D2950).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for routine vision frames and lens provided on July 27, 2020.
You asked the Plan to pay for frames and lens. You say that the items should be covered. The Plan denied your request. The Plan says item is not covered when provided out-of-network.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services only when an in-network vision provider is utilized.
We looked at the file and the Plan's rules. In-network providers must be used to receive your vision benefits, you went to an out-of-network provider. Based on this information, we decided that the Plan's rules for coverage of frames and lens have not been met. Therefore, we decided that the Plan does not have to pay for routine vision frames and lens provided on July 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit provided by a 
participating provider on July 23, 2020. 
 
You asked the Plan to waive the copayment for a follow-up office visit. You say that you were told that the 
copayment would be waived due to Covid-19. The Plan denied your request. The Plan says the correct 
copayment has been 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 $20 
copayment for physician/practitioner services/specialist.  
 
You have been asked to pay a $20 copayment for a follow-up office visit. A follow-up office visit falls within 
the physician/practitioner services/specialist 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 a specialist office visit provided by a participating provider on July 23, 2020.  
 
We note your complaint about being told that your copayment would waived because of Covid-19. Your 
complaint is a grievance that must be answered by the health plan. Medicare does not permit us to make a 
decision about these types of complaints.