Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the chiropractic visits to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the chiropractic visits. You say that you do not want to change providers in the middle of treatment. The Plan denied your request. The Plan says the provider is 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 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 provider at issue in this case is not a network provider with the Plan. 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 chiropractic visits. Our reviewer says that the services are not medically necessary. Our physician reviewer found the provided records do not support the medical necessity or reasonableness of the out-of-network chiropractic visits.

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 chiropractic visits have not been met. 

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 the chiropractic visits. Therefore, we decided that the Plan does not have to pre-approve the chiropractic visits to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power leg lifts, upgraded electronics, and extra payment for armrests.

You asked the Plan to pre-approve power leg lifts, upgraded electronics, and extra payment for armrests. 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 medically necessary.

The Plan follows Medicare rules. Medicare rules say that wheelchair accessories are only covered for certain indications. 

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 power leg lifts, upgraded electronics, and extra payment for armrests. Our reviewer says that the documentation does not support that the requested items are medically reasonable or necessary. Our physician reviewer found the enrollee has multiple sclerosis. There is no evidence that the enrollee has a condition that prevents 90 degree flexion at the knee or a cast or brace on the leg which prevents this flexion. There is no evidence of significant lower extremity edema. There is no evidence the enrollee requires a reclining back on a wheelchair. The enrollee does not need to operate three or more powered seating actuators through the drive control, a separate display (i.e., for alternate control devices),other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. The enrollee's strength and function in the upper extremities with the ability to feed and groom independently supports that the enrollee can control any power options through their own individual switches. The requested armrests exceed the enrollee's medical need as the approved power wheelchair already has moveable armrests. Therefore, the enrollee does not meet criteria for the requested 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 power leg lifts, upgraded electronics, and extra payment for armrests have not been met. Therefore, we decided that the Plan does not have to pre-approve power leg lifts, upgraded electronics, and extra payment for armrests.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on December 31, 2020.

You asked the Plan to pay for out of network services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for out of network physician services provided to the enrollee on December 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network medical services provided to the enrollee on July 16, 2020.

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization.

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 had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for out of network medical services provided to the enrollee on July 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for 2D oral/facial photographic images (D0350), unspecified preventative procedure (D1999), and core buildup services (D2950) provided March 23, 2021.

You asked the Plan to pay for 2D oral/facial photographic images, unspecified preventative procedure, and core buildup services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says these services are not covered under the supplemental benefit

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 2D oral/facial photographic images (D0350), unspecified preventative procedure (D1999), and core buildup services (D2950) provided March 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).

You asked the Plan to pre-approve a CGM. You say that you would like the Plan to reconsider their denial. The
Plan denied your request. The Plan says the enrollee does not meet criteria.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations,
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment
plan.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood
glucose testing at least four times per day, does not use insulin with at least three daily injections, and does not
require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this
information, we decided that Medicare rules for coverage of a CGM have not been met. Therefore, we decided
that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Myopro powered upper extremity range of motion assist device.

You asked the Plan to pre-approve Myopro powered upper extremity range of motion assist device. You say that you feel this device should be covered. The Plan denied your request. The Plan says the requested device is not medically necessary.

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 Myopro powered upper extremity range of motion assist device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found you are post a cerebrovascular accident. You have tried and failed physical and occupational therapy and modalities for the hemiparesis. The MyoPro is not known to be effective, based on scientific evidence, professional standards and expert opinion, in improving health outcomes in enrollees with a stroke.

The MyoPro is not in widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long-term outcomes for you, improve hemiparetic arm function, or be safe for long term use. There is insufficient evidence in the literature that this device will increase participation in bimanual activities. therefore, you do not meet criteria for the requested device. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Myopro powered upper extremity range of motion assist device have not been met. Therefore, we decided that the Plan does not have to pre-approve Myopro powered upper extremity range of motion assist device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power-operated scooter.

You asked the Plan to pre-approve a power-operated scooter. You say that this request is medically necessary.
The Plan denied your request. The Plan says equipment to be used outside of the home is not covered by
Medicare.

The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate
and needed for use inside the home.

The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not
have to pre-approve a power-operated scooter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a membership to the Renew Active Program.

You asked the Plan to pre-approve a membership to the Renew Active Program. You say that your orthopedic doctor recommended that you engage in swimming exercises to strengthen your knees. You say the fitness center does not participate in the select program but does participate in the Renew Active program. You say that all of the gymnasiums or fitness centers in the area which offer the select program do not have swimming pools. The Plan denied your request. The Plan says the requested service is not covered under the member's benefit contract.

The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers gym benefits only with the select program.

The Plan's rules for coverage of gym benefits have not been met because the requested service is not covered under your fitness benefit. Therefore, we decided that the Plan does not have to pre-approve a membership to the Renew Active Program.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided to the enrollee on August 27, 2020.

You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says due to the enrollee's hospice election at the time of service, this claim must be submitted to Original Medicare first for review.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for medical services provided to the enrollee on August 27, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-emergency transport (A0428), ground mileage (A0425), and basic support supplies (A0382) provided on December 23, 2020.

You asked the Plan to pay for the basic support supplies. You say that the enrollee received 2 separate trips from the hospital to their residence on the date of service in this case. The Plan denied your request.

The Plan says oxygen and other items and services provided as part of the transport are included in the fee schedule base payment rate and are not separately payable.

The Plan must follow Medicare rules. Medicare rules say that ambulance suppliers must accept the Medicare allowed charges as payment in full and may not bill or collect from the beneficiary any amount other than the unmet cost-sharing. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the basic support supplies have not been met. Specifically, the file indicates that that the Plan paid for the non-emergency transport and ground mileage which is considered payment in full. No additional payment for supplies is allowed. Therefore, we decided that the Plan does not have to pay for the non-emergency transport (A0428), ground mileage (A0425), and basic support supplies (A0382) provided on December 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network services provided to the enrollee on January 18, 2021.

You asked the Plan to pay for this service. You say that the enrollee was checked in with the Original Medicare card and not the proper insurance card. You would like the Plan to consider payment. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for out of network services provided to the enrollee on January 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on
May 21, 2021.

You asked the Plan to pay for out of network services. You say that this claim should be paid. The Plan denied
your request. The Plan says the enrollee did not have prior authorization for out of network care.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.

The provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for out of network physician services provided to the
enrollee on May 21, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health care provided out of network on April 27, 2021.

You asked the Plan to pay for out of network providers. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says you did not have prior authorization for out of network care.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided 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 outpatient mental health care provided out of network on April 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the power seat elevation feature (E2300).

You asked the Plan to pre-approve the power seat elevation feature. You say that this item is medically
necessary for activities of daily living. The Plan denied your request. The Plan says this item is not covered
according to Medicare rules.

The Plan must follow Medicare rules. Medicare rules say that the power seat elevation feature is statutorily
non-covered by Medicare.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the power seat elevation feature have not been met. Therefore, we decided that the Plan does not
have to pre-approve the power seat elevation feature (E2300).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit (99335) rendered by the out-of-network (OON) provider on April 8, 2021.

You asked the Plan to pay 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 the service was rendered by an out of network provider, without prior authorization.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the domiciliary or rest home visit (99335) rendered by the out-of-network (OON) provider on April 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on June 18, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the subsequent nursing facility care. You say that the service was provided with no adequate time frame to obtain authorization for the service. You say the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan 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 subsequent nursing facility care provided on June 18, 2020 by an out-of-network (OON) provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ophthalmic diagnostic imaging provided on March 31, 2021.

You asked the Plan to waive the copayment for the ophthalmic diagnostic imaging. You say that you were under the impression you received a routine eye exam. You are on a limited income and cannot afford the extra cost. The Plan denied your request. 

The Plan says since the medical eye exam will be denied to the provider, you will be held liable for the copayment of $32.51 for the ophthalmic diagnostic imaging performed.

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 $45 copayment for in-network specialty physician for other Medicare-covered outpatient diagnostic tests. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the standard $45 copayment for the ophthalmic diagnostic imaging.

You have been asked to pay a $32.51 copayment for the ophthalmic diagnostic imaging. The ophthalmic diagnostic imaging falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows the ophthalmic diagnostic imaging was performed. 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 ophthalmic diagnostic imaging provided on March 31, 2021.