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

We decided that the Plan does not have to provide a power mobility device with adjustable arm rests and elevating leg rests.
You asked the Plan to provide a power mobility device with adjustable arm rests and elevating leg rests. You say that the enrollee gets short of breath and needs a power mobility device with adjustable arm rests and elevating leg rests. The Plan denied your request. The Plan says the documentation does not support the medical necessity for the power mobility device.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The file does not show that the enrollee has a mobility deficit that impairs participation in MRADLs, their condition cannot be improved by a walker, cane or manual wheelchair, or they can safely operate the PMD being requested. There is no Home Assessment documentation or Specialty Evaluation documentation. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to provide a power mobility device with adjustable arm rests and elevating leg rests.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided
October 4, 2019 to October 25, 2019.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the cost sharing has been applied correctly to
the services provided.
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 enrollee's contract with the Plan clearly says that enrollees
must pay a $395 copayment each day for days 1-4 for inpatient hospital care.
The enrollee has been asked to pay a $1,580 copayment ($395 x 4 days) for inpatient hospital care. This means
that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing
is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the
Plan does not have to waive the copayment for the inpatient hospital care provided October 4, 2019 to
October 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Life Alert Device (E1399).
You asked the Plan to pre-approve the Life Alert device. You say that you live alone and would like coverage
of a life alert device because you have fallen multiple times and had a mini stroke. The Plan denied your
request. The Plan says this service is not covered under Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
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 the Life Alert Device (E1399).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 45 additional routine transportation trips.
You asked the Plan to pre-approve the additional trips. You say that you are appealing the denial for additional transportation. The Plan denied your request. The Plan says this request exceeds transportation the benefit limit.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 12 trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve 45 additional routine transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.
You asked the Plan to pre-approve a continuous glucose monitor. You say that a continuous glucose monitor
should be covered for your condition. The Plan denied your request. The Plan says you have not met criteria for
a continuous glucose monitor.
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. The record shows you are not insulin injection three or more times a
day. Based on this information, we decided that Medicare rules for coverage of a continuous glucose monitor
have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose
monitor.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for inpatient hospital care, for the enrollee.
You asked the Plan to pay for inpatient hospital care. You say that the stay is medically necessary. The Plan
denied your request. The Plan says that the stay is not medically necessary.
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 inpatient hospital care. Our reviewer says
that the documentation supports that the criteria for inpatient payment are met in this case. Our physician
reviewer found the review has determined that the record showed that at the time of inpatient admission the
admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency
department (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 inpatient hospital care have been met. Therefore, we decided that the Plan has to
pay for inpatient hospital care, for the enrollee.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the cleaning (D1110).
You asked the Plan to pre-approve the cleaning (D1110). You say that the service is medically necessary. The
Plan denied your request. The Plan says the service exceeds the maximum count allowed per period
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, there is a benefit limit for the cleaning.
The plan clearly states two standard adult dental cleaning procedures are covered every plan year. The records
show the Plan paid for cleanings on January 24, 2020 and May 27, 2020, which exhausted the benefit.
Therefore, we decided that the Plan does not have to pre-approve the cleaning (D1110).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee sleeve (A4667).
You asked the Plan to pre-approve a knee sleeve. You say that you wish for this to be approved because at the
moment you do not wish to be operated The Plan denied your request. The Plan says fabric supports are not
covered by Medicare.
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 knee sleeve have not been met. Therefore, we decided that the Plan does not have to pre-approve
a knee sleeve (A4667).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a walker, folding, wheeled, adjustable or fixed height.
You asked the Plan to pre-approve a walker (E0143). You say that the enrollee needs a rollator because of
medical conditions. The Plan denied your request. The Plan says there is insufficient clinical information to
make a determination.
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. There are no codes, supplier information, or clinical information.
Based on this information, we decided that Medicare rules for coverage of a walker (E0143) have not been met.
Therefore, we decided that the Plan does not have to pre-approve a walker, folding, wheeled, adjustable or
fixed height.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMEMS device (33289, C2624)
You asked the Plan to pre-approve the CardioMEMS device. You say that the device is medically necessary.
The Plan denied your request. The Plan says this item is considered investigational for this application at this
time.
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 CardioMEMS device. Our reviewer
says that the requested services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the efficacy of the CardioMEMS device is uncertain at this time according to leading
authorities and not recommended in current guidelines for the treatment of heart failure.
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 CardioMEMS device have not been met. Therefore, we decided that the
Plan does not have to pre-approve a CardioMEMS device (33289, C2624).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the surgical placement of implant body (D6010),
custom fabricated abutment (D6057) and metal-ceramic crown (D6066).
You asked the Plan to pre-approve the surgical placement of implant body (D6010), custom fabricated
abutment (D6057) and metal-ceramic crown (D6066). You say that the implant would allow her to chew and
lessen the chance of compromising tooth #15. The Plan denied your request. The Plan says the services are not
covered benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the
surgical placement of implant body (D6010), custom fabricated abutment (D6057) and metal-ceramic crown
(D6066).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on
February 24, 2020.
You asked the Plan to waive the copayment for the ambulance transport. You say that you did not know there
would be a copayment. The Plan denied your request. The Plan says that cost shares are a contractual
obligation.
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 $220
copayment for each one-way Medicare-covered ground trip.
You have been asked to pay a $220 copayment for the ambulance transport. The ambulance transport falls
within the one-way Medicare-covered ground trip benefit category. This means that you have been asked to
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the
copayment for the ambulance transport provided on February 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the CPAP and supplies to be provided by an out of
network provider.
You asked the Plan to pre-approve the CPAP and supplies. You say that you need a CPAP as you cannot
breathe but you are dissatisfied with the Plan's provider. The Plan denied your request. The Plan says the
CPAP and supplies are available 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 CPAP and supplies to be provided by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Xiaflex injection provided on November
12, 2019.
You asked the Plan to waive the coinsurance for the Xiaflex injection. You say that this procedure was been
approved multiple times before and that insurance has paid for it. The Plan denied your request. The Plan says
you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% for
of the Medicare-allowed amount when administered in an office/clinic.
You have been asked to pay $877.68 which is 20% of the allowed amount for the Xiaflex injection. The
allowed amount is $4,388.40. ($4,388.40 x 20% = $877.68). The Xiaflex injection falls within the "Medicare
Part B prescription" 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 the Xiaflex
injection provided on November 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued rental of an oxygen concentrator.
You asked the Plan to pre-approve continued rental of an oxygen concentrator. You say that you need the
oxygen concentrator. The Plan denied your request. The Plan says they requested medical necessity
documentation from your physician but did not receive any.
The Plan must follow Medicare rules. The rules say that for patients with arterial PO2 at or above 60 mm Hg or
arterial O2 saturation at or above 90%, there is a rebuttable presumption of non-coverage for home oxygen.
We looked at the file and Medicare rules. There is no medical documentation supporting compliance. Based on
this information, we decided that Medicare rules for coverage of the oxygen concentrator have not been met.
Therefore, we decided that the Plan does not have to pre-approve continued rental of an oxygen concentrator.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the group therapeutic procedures (97150), mechanical
traction therapy (97012), and the self-care management training (97535) provided on January 2, 2020.
You asked the Plan to pay for the group therapeutic procedures, mechanical traction therapy, and the self-care
management training. You say that you are requesting a reconsideration of the Plan's denial for payment. The
Plan denied your request. The Plan says these services are not a covered benefit under your contractual policy.
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 services at issue are not manual manipulation of the spine. Therefore, we decided
that the Plan does not have to pay for the group therapeutic procedures (97150), mechanical traction therapy
(97012), and the self-care management training (97535) provided on January 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve four periodontal scalings and root planings.
You asked the Plan to pre-approve the scalings and planings. You say that a regular cleaning will not correct
the daily issues you have with your mouth. You also say that you are in extreme daily chronic pain and
discomfort. The Plan denied your request. The Plan says these services exceed the benefit allowance. The Plan
also says that this service is allowed one time in twenty-four months, and the records show that you have
received this service less than twenty-four months ago.
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, periodontal deep cleaning are limited
to 1 per quadrant every 2 years. The record shows that you received a periodontal scaling and root planing on
the upper left quadrant on January 15, 2019, and periodontal scalings and root planings of the lower right,
lower left, and upper right quadrants on January 25, 2019, and you periodontal deep cleaning benefit has been
exhausted. Therefore, we decided that the Plan does not have to pre-approve four periodontal scalings and root
planings.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Q-Logic joystick, height adjustable receiver,
modular footplate extension, accessory bar and conform foot double footbox.
You asked the Plan to pre-approve a Q-Logic joystick, height adjustable receiver, modular footplate extension,
accessory bar and conform foot double footbox. You say that the enrollee needs a Group 3 power wheelchair
and accessories. The Plan denied your request. The Plan says the joystick is included, the height adjustable
receiver and accessory bar are not medical in nature. The modular footplate extension is not medically
necessary and the comfort foot double foot-box was not requested under the correct code.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
The height adjustable receiver and accessory bar at issue in this appeal 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. The joystick is included and not separately payable. The CPT code for the footbox appears
to be E0954. Therefore, we decided that the Plan does not have to pre-approve the Q-Logic joystick, height
adjustable receiver, modular footplate extension, accessory bar or conform foot double footbox.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MyoPro myoelectric orthosis (L8702).
You asked the Plan to pre-approve the orthosis. You say that given that traditional rehab strategies have been
tried and failed, the enrollee has been referred by his physician for myoelectric orthotic restoration. The Plan
denied your request. The Plan says this item is considered experimental and investigational. There is
insufficient evidence of its effectiveness.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered. The rules also say that experimental and investigational devices are not covered.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve
the MyoPro myoelectric orthosis (L8702).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital services provided
from January 12, 2020 to January 23, 2020.
You asked the Plan to waive the copayment for the inpatient hospital services. You say that this admission
should not be separate from your previous admission. The Plan denied your request. The Plan says that the
claim processed correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300
copayment for days 1-5 of inpatient hospital care per day, per admission.
You have been asked to pay a $1,500 copayment for the inpatient hospital services. The inpatient hospital
services fall within the days 1-5 of inpatient hospital care benefit category. This means that you have been
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have
to waive the copayment for the inpatient hospital services provided from January 12, 2020 to January 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral-complete series x-ray provided on July 12, 2019.
You asked the Plan to pay for the intraoral-complete series x-ray. You say that the dental clinic didn't check your eligibility for coverage before taking the x-rays. You say that you shouldn't have to pay for the x-rays. The Plan denied your request. The Plan says full series x-rays are only allowed once every 5 years.
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 also has a maximum benefit amount of one full series x-ray every five years. The records show that the Plan covered a full series x-ray on January 8, 2015, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the intraoral-complete series x-ray provided on July 12, 2019.