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

We decided that the Plan does not have to pre-approve repairs to a power mobility device (K0108, E2609). You asked the Plan to pre-approve the repairs. You say that the repairs are medically necessary.The Plan denied your request. The Plan says no information regarding cost vs. replacement of the power mobility device has been provided. No documentation of warranty status of the equipment was provided.The Plan must follow Medicare rules. Medicare rules say that say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. We looked at the file and Medicare rules. The wheelchair was purchased in 2018. No documentation of warranty status was provided to the plan. No information regarding the cost of repairs was provided. Based on this information, we decided that Medicare rules for coverage of the repairs have not been met.Therefore, we decided that the Plan does not have to pre-approve repairs to a power mobility device (K0108, E2609).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laser eye surgery provided on February 13, 2020.
You asked the Plan to waive the copayment for the laser eye surgery. You say that you paid $325. You say that you don't understand the charges. The Plan denied your request. The Plan says the copayment applied 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 $325 copayment for each Medicare-covered outpatient surgery at an ambulatory surgical center. You have been asked to pay $280.65, which is less than the standard $325 copayment for the laser eye surgery.
Service
Allowed Amount
Standard Copayment
Member Liability
Laser Eye Surgery
$280.65
$325
$280.65
The laser eye surgery falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 laser eye surgery provided on February 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete lower denture (D5120).
You asked the Plan to pre-approve a complete lower denture. You say that the item is necessary since your current denture no longer fits. The Plan denied your request. The Plan says the benefit has been exhausted.
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 one lower complete denture every five years. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a complete lower denture have not been met. The record shows that you received a complete lower denture on September 18, 2017. This means that you are not eligible for health plan coverage of a complete lower denture at this time. Therefore, we decided that the Plan does not have to pre-approve a complete lower denture (D5120).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an outpatient visit provided on January 15, 2020 by an out of network (OON) provider.
You asked the Plan to pay for an outpatient visit. You say that you would like this appeal reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the referring provider is also out-of-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 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 an outpatient visit provided on January 15, 2020 by an out of network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Partially Favorable

We decided that the Plan has to reduce the copayments for the brain mapping and transcranial magnetic
stimulation. We decided that the Plan does not have to waive the copayment for transcranial magnetic
stimulation.
You asked the Plan to waive the copayment for the brain mapping and transcranial magnetic stimulation. You
say that the Medicare appeal was approved. You say that the member should be reimbursed. The Plan says that
the copayments applied correctly.
We decided that the Plan has to reduce the copayment for the brain mapping and transcranial magnetic
stimulation.
The brain mapping is considered a diagnostic test, which applies a $40 copayment. The transcranial magnetic
stimulation is considered an outpatient mental health service, which also applies a $40 copayment. Therefore,
we decided that the Plan has to reduce the copayment for the brain mapping and transcranial magnetic
stimulation to $40 for each visit.
We also decided that the Plan does not have to waive the copayment for the brain mapping and
transcranial magnetic stimulation.
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 $40
copayment for diagnostic procedures and tests at an in-network specialist's office and a $40 copayment for
outpatient mental health care at an in-network specialist's office. Therefore, we decided that the Plan does not
have to waive the copayment for the brain mapping transcranial magnetic stimulation.
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
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 5 additional physical therapy visits.
You asked the Plan to pre-approve the additional physical therapy. You say that you would like reconsideration because physical therapy has been helpful for your condition. The Plan denied your request. The Plan says additional physical therapy is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the additional physical therapy. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found you do not need the ongoing unique skills of a professional therapist to safely and effectively provide 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 the additional physical therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve 5 additional physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral.
You asked the Plan to pre-approve the referral. You say that it would be detrimental to not continue the psychotherapy. The Plan denied your request. The Plan says this is not considered a billable provider.
The Plan must follow Medicare rules. Medicare rules say that services must be provided by providers who are enrolled in the Medicare program. The requested provider is not eligible to bill Medicare. Based on this information, we decided that Medicare rules for coverage of the referral have not been met. Therefore, we decided that the Plan does not have to pre-approve a referral. We decided that the Plan does not have to pre-approve a referral.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for the fundus photography (92250) provided
on February 17, 2020.
You asked the Plan to issue reimbursement for this service. You say that you are requesting a reconsideration
of the Plan's denial for payment. The Plan denied your request. The Plan says this service is not a covered
benefit under your contractual policy.
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. Based on this information, we decided that the Plan's rules for
coverage of this service have not been met.
Specifically, the service provided was an advanced eye exam. The record indicates that you elected this
optional procedure with an indicated additional cost. Your vision benefit covers only that of a routine eye
exam. Therefore, we decided that the Plan does not have to issue reimbursement for the fundus photography
(92250) provided on February 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe hearing aids and services provided on January 20, 2020 by a non-participating provider.You asked the Plan to pay forthe services. You say that you are appealing for reconsideration of the denied charges.The Plan denied your request. The Plan says you exhausted your maximum benefit allowance.Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the services have not been met. Review of the file show that you received the hearing aids and services on January 20, 2020 froma non-participating provider. Your benefit covers $1000 for both hearing aids which was applied on the claim, anything over the benefit becomes member responsibility.Therefore, we decided that the Plan does not have to pay forthe hearing aids and services provided on January 20, 2020 by a non-participating provider.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approvea panniculectomy.You asked the Plan to pre-approvethe requested service. The Plan denied your request. The Plansays that services performed solely to enhance the enrollee's appearance in the absence of functional abnormalities, the procedure is considered cosmetic and not covered.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 thecase file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the requested service. Our physician reviewer found that the enrollee had undergone a gastric sleeve procedure in October 2018. She had lost approximately 80 pounds. Her current weight is 188 pounds, with a goal of 150 pounds. She has been having increasing issues with her abdominal pannus. She has been having intermittent rashes underneath her abdominal pannus. She has been prescribedlotrisone cream, zinc oxide and nystatin powder for her chronic rashes for over a year. Examination notes a grade 1 abdominal pannus. The enrollee has failed typical dermatologic management with multiple prescribed medications. Panniculectomy would likelyresolved or significantly improve her functional impairment. Therefore, this procedure directly satisfies 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 the requested service have been met. Therefore, we decided that the Plan has to pre-approvea panniculectomy.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-approvea phone alert bracelet.You asked the Plan to pre-approvethe bracelet. You say that this is medically necessary.The Plan denied your request. The Plan says this is considered a convenience item, and is not used to treat a medical condition.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  We asked our physicianreviewer 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 bracelet. Our reviewer says that  Our physician reviewer found 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-approvea phone alert bracelet.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveanesthesia for the enrollee's endovenous ablation therapy.You asked the Plan to pre-approveanesthesia services. You say that the enrollee will have unnecessary pain, which can be avoided if anesthesia is used.The Plan denied your request. The Plan says the enrollee does not have specific risk factors that require oversight by a separate anesthesia provider.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 anesthesia services. Our physician reviewer found that the proposed procedure is radiofrequency ablations of bilateral great saphenous veins. There is no documentation that the enrollee has co-morbidities which would support the need for monitored anesthesia. As well, the proposed procedure is typically performed in an ambulatory setting with minimal sedation and without the services of an anesthesiologist. There is nothing contained in the submitted documentation to warrant anesthesia services for this procedure. Therefore, the use of anesthesia as medically reasonable and necessary for this procedure.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of anesthesia services have not been met.Therefore, we decided that the Plan does not have to pre-approveanesthesia for the enrollee's endovenous ablation therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet injections, lumbar/sacral (64493).
You asked the Plan to pre-approve facet injections, lumbar/sacral. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that there is no non-facet pathology that could explain the source of the patient's pain, such as fracture, tumor, infection, or significant deformity. 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 facet injections, lumbar/sacral. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has an untreated vertebral body fracture. Therefore, the request does not meet the coverage criteria and is deemed not medically reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of facet injections, lumbar/sacral have not been met. Therefore, we decided that the Plan does not have to pre-approve facet injections, lumbar/sacral (64493).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care in an IRF. The enrollee's current medical status does not require intensive physician or nursing oversight in an IRF at this time as he continues to have confusion and lethargy and is not ready for transfer to a rehab at this time. The enrollee may benefit from additional multiple therapies, however the enrollee's functional level which is noted to be limited due to lethargy does not require or indicate that this therapy can be tolerated and must be in an IRF with an intensive level program.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve standard wheelchair side guards.
You asked the Plan to pre-approve aluminum rigid removable standard side guards. You say that you need the
wheelchair and accessories. The Plan denied your request. The Plan says the side guards 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 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 standard wheelchair side guards.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor sensor.
You asked the Plan to pre-approve the sensor. You say that this is medically necessary. The Plan denied your
request. The Plan says the requested code is not a covered benefit.
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 sensor. Our reviewer says that the requested sensor is not considered medically reasonable and necessary in this case. Our physician reviewer found the requested device does qualify as therapeutic. There is no documentation that the enrollee is consistently monitoring his blood sugars four or more times daily. 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 sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor sensor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe 4 gingival irrigations (D4921 x4), bone replacement graft (D7953), and 8 core buildups, including any pins when required (D2950 x8).You asked the Plan to pre-approvethe gingival irrigations, bone replacement graft, and core buildups. The Plan denied your request. The Plan says these services are not covered by Medicare or the Plan.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvethe 4 gingival irrigations (D4921 x4), bone replacement graft (D7953), and 8 core buildups, including any pins when required (D2950 x8)
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 the services are necessary. The Plan denied your request. The Plan says the care required can be provided in the current inpatient hospital setting.
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 in this case, there is no documentation provided necessitating admission to a LTACH. The enrollee is getting acute care and acute care services have not been denied. The review has determined that the enrollee does not require services at the LTACH that are not available at the acute care hospital where they are currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 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.