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

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that the requested shower chair is necessary for you. You say that you live alone and you are in a wheelchair. You stated that you are unable to wash yourself without the requested shower chair. You say that you are afraid of slipping in the shower and having another accident. You stated that you have fallen previously and injured your hand. You asked the Plan to reconsider their denial because you need the requested chair in order to be able to take a shower. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for Lumex combination sit-to-stand frame/table system with seat lift feature purchased November 20, 2019.You asked the Plan to pay for the standing table. You say that you did not purchase the equipment from a traditional medical equipment supplier because this was urgently needed to assist with transfers and you got it in 2 days and the cost was cheaper.The Plan denied your request. The Plan says this item is not a covered under Medicare or the Plan. 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.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 pay for Lumex combination sit-to-stand frame/table system with seat lift feature purchased November 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran office visit provided on February 7, 2020.You asked the Plan to waive the copayment foran office visit. You say that you left the office before seeing the doctor and should not be responsible for the copayment.The Plan denied your request. The Plan says the copayment you are being charged is correct.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 $35 copayment for in-network Physician specialist services. You have been asked to pay a $35 copayment for an office visit. Office visits fall within the Physician/Practitioner services, including doctor's office visits 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 foran office visit provided on February 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stair lift.
You asked the Plan to pre-approve a stair lift. You say that you have an extremely poor gait and multiple medical conditions. You say that these conditions have made it virtually impossible for you to travel up and down your stairs. You stated that the shower in your home is in your basement and so you are forced to move up and down the stairs in order to maintain good hygiene. You say that you are worried that you will fall and injure yourself. You asked the Plan to reconsider their denial of the requested stair lift. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they are not primarily medical in nature. While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a stair lift.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on February 26, 2020.
Please note, the Plan has confirmed that the provider has submitted the claim to the primary insurer on June 25,
2020.
You asked the Plan to pay for the ambulance services. You say that the Plan should pay this claim. The Plan
denied your request. The Plan says you must first file a claim with the auto insurance company.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for
services until the claim for those services has gone to the primary insurer. However, plans are still required to
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a
bill for reimbursement to the primary insurer.
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the
provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible
for the ambulance services until the primary insurer has denied the claim for these services. Therefore, we
decided that the Plan does not have to pay for the ambulance services provided on February 26, 2020.
Please note, the Plan has confirmed that the provider has submitted the claim to the primary insurer on June 25,
2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient skilled nursing facility (SNF) care provided December 9, 2019 to December 31, 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 copayment 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). Your contract with the Plan clearly says that you must pay a $0 copayment per day, for days 1-20 and a $167.50 copayment per day, for days 21-100, for inpatient skilled nursing facility care. You have been asked to pay a $502.50 copayment ($167.50 x 3days) for inpatient skilled nursing facility care. 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 skilled nursing facility (SNF) care provided December 9, 2019 to December 31, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the complete upper denture (D5110).
You asked the Plan to pre-approve the complete upper denture. You say that the last dentures were too big and uncomfortable. You say that your last dental office should be reimbursed so you can get another set that fits. The Plan denied your request. The Plan says the service is only covered 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 of one complete upper denture every 5 years. The records show that you received a complete upper denture on January 29, 2016, which exhausted your benefit. Therefore, we decided that the Plan does not have to pre-approve the complete upper denture (D5110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series x-rays (D0210), oral/facial photographic
images (D0350) and panoramic x-rays (D0330) provided February 25, 2020.
You asked the Plan to pay for the x-rays. You say that you are requesting an appeal based on the necessity of
the exam in order to be sure of what was necessary to do to try to insure your dental and physical health. The
Plan denied your request. The Plan says these services are not covered under the plan 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 pay for the
complete series x-rays (D0210), oral/facial photographic images (D0350) and panoramic x-rays (D0330)
provided February 25, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray (71045) provided March 28, 2020.
You asked the Plan to pay for the chest x-ray. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim is a duplicate.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 71045 is not supported in the medical record. Specifically, the same code was paid on the same date of service under claim 820200931285244. The claim at issue is a duplicate. Based on this information, we decided that Medicare rules for coverage of the chest x-ray have not been met. Therefore, we decided that the Plan does not have to pay for the chest x-ray (71045) provided March 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance provided on March 3, 2020.You asked the Plan to pay for the periodontal maintenance. You say that this service was covered by the Plan in 2019, and you expected continued coverage in 2020. You also say that a Plan representative told you that your Plan's dental coverage had changed, but you were not informed of this change during the open enrollment period last year.The Plan denied your request. The Plan says this service is not covered.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 pay for the periodontal maintenance provided on March 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve these OON services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services can be provided by a 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 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 medical services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for the laser therapy provided January 21, 2020
to February 11, 2020.
You asked the Plan to issue reimbursement for the laser therapy. 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 issue reimbursement for the laser therapy provided January 21, 2020 to
February 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean expandable controller, harness and electronic connection.You asked the Plan to pre-approvethese items. You say that  The Plan denied your request. The Plan says that there is not a medical need to control this power option through the joystick.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 these items. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Your functional ability and upper extremity strength do not indicate that you require the requested devices. The requested devices exceed your medical need as you should be able to control the device with any individual switches that would be included in a power mobility device. Our physician reviewer found that your condition does not meet Medicare criteria for these items.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these items have not been met.Therefore, we decided that the Plan does not have to pre-approvean expandable controller, harness and electronic connection.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for portable x-ray services (R0070) provided March 3, 2020.
You asked the Plan to pay for the portable x-ray services. You say that the services were medically necessary.
The Plan denied your request. The Plan says the claim was submitted incorrectly.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT code R0070 is not supported in the medical record. Specifically, the record shows the claim
was submitted with an invalid place of service code. Based on this information, we decided that Medicare rules
for coverage of the portable x-ray services have not been met. Therefore, we decided that the Plan does not
have to pay for portable x-ray services (R0070) provided March 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgical removal of a tooth with dental code D7210.
You asked the Plan to pre-approve dental service. You say that based on your dental history this tooth has been pulled, however a portion of the tooth obviously broke off and has worked its way into your gum line. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because your tooth number 3 was extracted on October 5, 2016 and this service is only covered once per tooth per lifetime.
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 surgical removal of a tooth once per tooth per lifetime. We looked at this physician's review, the file, and Medicare rules. The requested tooth has already received a surgical extraction, therefore the benefit for extraction of this tooth has been exhausted. Based on this information, we decided that the Plan's rules for coverage of dental service have not been met. Therefore, we decided that the Plan does not have to pre-approve surgical removal of a tooth with dental code D7210.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee does not need frequent physician visits, or special equipment.
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 physician reviewer found that the enrollee is at contact guard assist for bed mobility, minimal assist for toilet transfers, and minimal assist for ambulation using a wheeled walker. The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora Mirena IUD.You asked the Plan to pay forthe Mirena IUD. You say that you would like reconsideration because this service will help treat the member's condition.The Plan denied your request. The Plan says the record does not indicate that the member has endometrial hyperplasia.The Plan must follow Medicare rules. Medicare rules say that the use of a progestin containing IUD may be approved for use in the Medicare beneficiary who presents with endometrial hyperplasia without atypia.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Mirena IUD have not been met. Specifically, IUDs are not covered unless the beneficiary has endometrial hyperplasia without atypia. The record does not indicate that the member has this condition.Therefore, we decided that the Plan does not have to pay fora Mirena IUD.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of
network (OON) provider.
You asked the Plan to pre-approve physical therapy. You say that this is the only provider you know who has
the skill to adjust your insoles so that your toes do not rub when you walk. The Plan denied your request. The
Plan says the denial of authorization for these services is correct, because this provider is out-of-network with
the Plan and you can be treated by an in-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 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 medical services to be provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on July 11, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a
physician.
We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation.
Based on this information, we decided that Medicare rules for coverage of these services have not been met.
Therefore, we decided that the Plan does not have to pay for the drug testing rendered on July 11, 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 records provided support the need for IRF care. The Plan denied your request. The Plan says the enrollee does not need an intensive team approach for care. The Plan says that the enrollee does not have be seen by a rehab doctor 3 times a week and does not need an inpatient rehab stay to get better. The Plan says that the enrollee can receive the services needed in another, less intensive setting.
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. The enrollee does require physical therapy and occupational therapy services but, based on the medical records provided, the enrollee does not require an intensive inpatient rehabilitation therapy program. There is concern that the enrollee will not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Care at the skilled nursing facility level appears to be more appropriate in this case.
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.