Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay forphysical therapy services (97116, 97530, 97110) provided on March 11, 2020.You asked the Plan to pay forphysical therapy services. You say that these services were necessary to restore the enrollee's functional abilities.The Plan denied your request. The Plan says these services were 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 pay for physical therapy services. Our reviewer says that skilled services were not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the medical records show that the enrollee had prior therapy, but the documentation does not reveal that she has had significant objective functional improvement from prior therapy or that she requires the unique skills of a professional therapist to safely and effectively provide treatment, which appears to be repetitive. The records do not show that  the requested services are not part of a maintenance program and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain the patient's current condition or to prevent or slow further deterioration.We looked at this physician's review, the file,and Medicare rules. Based on this information, we decided that Medicare rules for coverage of physical therapy services have not been met.Therefore, we decided that the Plan does not have to pay forphysical therapy services (97116, 97530, 97110) provided on March 11, 2020
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe hospital services provided on February 22, 2020.You asked the Plan to waive the copayment forthe hospital services. You say that you should only have an emergency visit copayment.The Plan denied your request. The Plan says that the hospital billed this as an observation and you were charged the correct copayment.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 each Outpatient Hospital Observation stay. You have been asked to pay a $300 copayment for the hospital services. The hospital services fall within the Outpatient Hospital Observation stay 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 forthe hospital services provided on February 22, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean additional 17 hours per week of home health aide services.You asked the Plan to pre-approvean additional 17 hours per week of home health aide services. You say that the services are necessary.The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or 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 an additional 17 hours per week of home health aide services. Our reviewer says that the services are not medically necessary. Our physician reviewer found therequested additional home health aide services are not reasonable or necessary to the treatment of the patient's illness or injury by the skilled professional staff.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an additional 17 hours per week of home health aide services have not been met.Therefore, we decided that the Plan does not have to pre-approvean additional 17 hours per week of home health aide services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forthe remaining self-administered drugs provided from February 12, 2020 to February 14, 2020.You asked the Plan to pay forthe remaining self-administered drugs. You say that the drugs were self-administered in the hospital. You also say you do not have an itemized bill.The Plan denied your request. The Plan says Medicare guidance says if the covered drugs you get in a hospital outpatient setting are part of your outpatient services, you pay a copayment for the services.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 pay forthe remaining self-administered drugs provided from February 12, 2020 to February 14, 2020.Benefits for the remaining self-administered drugsmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay fora colonoscopy (45380) provided on December 13, 2018.You asked the Plan to pay fora colonoscopy. You say that you were given incorrect insurance information.The Plan denied your request. The Plan says this was not filed timely.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service.The record shows that a claim for a colonoscopy was not filed until April 21, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay fora colonoscopy (45380) provided on December 13, 2018.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forthe self-administered drugs provided from February 27, 2020 to February 28, 2020.You asked the Plan to pay forthe self-administered drugs. You say that you were not advised by the hospital that you were going to be charged for this, but were informed that you could not take the medications you brought from home.The Plan denied your request. The Plan says self-administered drugs are not covered under Part B or your medical benefit.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are coveredby Medicare Part B.Therefore, we decided that the Plan does not have to pay forthe self-administered drugs provided from February 27, 2020 to February 28, 2020.Benefits for the self-administered drugsmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140) and resin-based composite - one surface, anterior (D2330) provided on March 12, 2020.

You asked the Plan to pay for the dental services. You say that the services were necessary. The Plan denied your request. The Plan says the services are not a covered benefit under 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. The services are not listed in your EOC as a covered benefit; therefore, the services are not covered. Therefore, we decided that the Plan does not have to pay for extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140) and resin-based composite - one surface, anterior (D2330) provided on March 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical extraction provided on April 6, 2020.
You asked the Plan to pay for the extraction. You say that the extraction was not done by a surgeon, but by
your dentist. You also say that this was an emergency extraction. The Plan denied your request. The Plan says
this service is not a covered benefit. The Plan also says that your plan allows for simple extractions under the
basic benefits, but surgical extractions are classified as a major service, which is not covered by your 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, you are responsible for 100% of the
cost for Class 3 Major Services. Therefore, we decided that the Plan does not have to pay for the surgical
extraction provided on April 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power adjustable seat height and bag hooks. 
 
You asked the Plan to pre-approve power adjustable seat height and bag hooks. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested items are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The rules also say that a power seat elevation feature is non-covered. 
 
The bag hook at issue in this appeal does not serve a purpose that is primarily medical in nature. The requested power adjustable seat height is not a covered benefit. 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 preapprove power adjustable seat height and bag hooks
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for Computed Tomography (CT) of the spine (72126) and Myelography via lumbar injection (62302) provided January 22, 2020.
You asked the Plan to waive the copayments for the CT scan and Myelography.. You say that only one copayment should be charged. The Plan denied your request. The Plan says there are separate copayments for each procedure. The correct cost-sharing was 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 $225 copayment for Diagnostic Radiology and Outpatient Surgery. You have been asked to pay two $225 copayments for the CT scan and the Myelography. the CT scan and Myelography fall within the Diagnostic Radiology and Outpatient Surgery 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 copayments for Computed Tomography (CT) of the spine (72126) and Myelography via lumbar injection (62302) provided January 22, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the respite care provided on August 27, 2019 to December 31, 2019 by an out of network (OON) provider.
You asked the Plan to pay for respite care. You say that you were told that your mother was able to receive care at a facility and that the Plan would cover any amount per month that they charge and request an exception for the out of network facility. The Plan denied your request. The Plan says The plan cannot pay a provider who is not eligible to participate in Medicare. If you go to a provider who is not eligible to participate in Medicare, you will be responsible for the full cost of the services you receive.
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 respite care provided on August 27, 2019 to December 31, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown porcelain fused to high noble metal, tooth #28 (D2750), for the enrollee. 
 
You asked the Plan to pre-approve the dental services. You say that the service is medically necessary. The Plan denied your request. The Plan says the rules 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 dental services when the services are medically necessary and reasonable.  
 
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 dental services. Our physician reviewer found the criteria for crowns under the Plan have not been met. Tooth #28 appears to be intact as seen on the provided x-ray, and there is no apparent need for a restoration of any kind. The Plan allows for crown restorations only where there is "pathologic destruction to tooth #28 by caries or trauma involving three or more surfaces and at least one cusp." In this instance there are no clearly involved surfaces, and no cuspal damage seen. Periodontal support is marginal particularly on the distal aspect, however the criteria for periodontal support is not applicable as the tooth is not in need of a crown based on amount of remaining tooth structure. The criteria for a crown has not been met. 
 
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 the dental services have not been met. Therefore, we decided that the Plan does not have to pre-approve a crown porcelain fused to high noble metal, tooth #28 (D2750), for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forperiodic oral evaluation -established patient (D0120) and prophylaxis -adult (D1110) provided on September 20, 2019by an out-of-network provider.You asked the Plan to pay forthe dental services. You say that you are requesting reimbursement of services rendered.The Plan denied your request. The Plan says you do not have out-of-network benefits.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan saysthat 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.Review of the file show that you received a periodic oral evaluation -established patient (D0120) and prophylaxis -adult (D1110) on September 20, 2019 provided by an out-of-network provider. 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 thisappeal. 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 forperiodic oral evaluation -established patient (D0120) and prophylaxis -adult (D1110) provided on September 20, 2019 by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for Breast prosthesis, mastectomy bra with integrated breast
prosthesis form (L8001) provided December 17, 2019.
You asked the Plan to pay for the breast prosthesis. You say that the records provided should support the
necessity of the service. The Plan denied your request. The Plan says the billed service cannot be verified.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a
physician order and proof of delivery.
The record does not contain a valid physician order for the supplies provided in this case. The record shows
that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we
decided that the Plan does not have to pay for Breast prosthesis, mastectomy bra with integrated breast
prosthesis form (L8001) provided December 17, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that the requested IRF admission is medically necessary.
The Plan denied your request. The Plan says the requested IRF care is not considered medically reasonable and
necessary based on Medicare guidelines.
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 enrollee was admitted to acute care on 7/12/20 for dizziness, difficulties with
ambulation, and left foot cellulitis. The member was diagnosed with pneumonia. Co-morbid conditions include
hypertension and prostate cancer. He responded to medical management and is now non-toxic and afebrile. He
is stand-by assist/minimal assist for transfers and basic activities of daily living.
Records do not indicate that there are significant, or complex medical/nursing issues that could not be
addressed at a lesser level of care. Ongoing pain medication and other medication management, wound care,
and daily therapy can be provided at a lesser level of care. In this case, the member is mostly minimal/standby
assist for functional transfers and activities of daily living and a less intensive, longer duration of therapy will
allow for measurable gains to be attained within a reasonable, and predicted period. An IRF intensity is not
warranted.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for specialty care transport provided on March 2, 2019. 
 
You asked the Plan to pay for specialty care transport (E0434). You say that the claim was timely. The Plan denied your request. The Plan says the claim was untimely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for specialty care transport (E0434) was not filed until March 4, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for specialty care transport provided on March 2, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe eyewear purchased on February 18, 2020 from an out-of-network provider.You asked the Plan to pay forthe eyewear. You say that you were told by an insurance agent that if you went to an optical provider that was not a network supplemental vision provider that you could fill out a reimbursement form and you would be reimbursed $250.The Plan denied your request. The Plan says you do not have out-of-network benefits. 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.Review of the file show that you purchased the eyewear on February 18, 2020 from an out-of-network provider. Your EOC states, you must use an in-network supplemental vision provider for routine coverage including; routine exam, retinal imaging and eyewear allowance. 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 forthe eyewear purchased on February 18, 2020 from an out-of-network provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approvehome health care services.You asked the Plan to pre-approvehome health care services. You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says you are not homebound per Medicare criteria.The Plan must follow Medicare rules. The rules say that an enrollee must be homebound for home health care services to be covered. The file does not show that you are homebound.Therefore, we decided that the Plan does not have to pre-approvehome health care services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the oxygen concentrator provided on December 5, 2019 by an out of network provider.
You asked the Plan to reimburse you for the oxygen concentrator. You say that you needed the oxygen concentrator for overnight oxygen on the cruise ship. The Plan denied your request. The Plan says the oxygen concentrator was provided by an out of network provider.
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 reimburse you 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 reimburse you for these items/services. Therefore, we decided that the Plan does not have to reimburse you for the oxygen concentrator provided on December 5, 2019 by an out of network provider.