Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve services of home health/hospice aide (HHA) in home health or hospice settings, each 15 minutes (CPT code G0156).  You asked the Plan to pre-approve the services. You say that you cannot be left alone for hours, you get dizzy and may fall so you are afraid to get up to go to the bathroom. The Plan denied your request. The Plan says your request for home health aide services is not medically necessary because you are not receiving skilled services. The Plan states you do have a personal home care benefit in your plan which may be able to meet some of your needs and you may discuss this with your provider.  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 the services. Our physician reviewer found the health plan's denial should be upheld. You do not have documented skilled nursing needs. You do not have documented skilled therapy needs. As such, concomitant HHA services are not medically necessary, reasonable or covered.  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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve services of home health/hospice aide (HHA) in home health or hospice settings, each 15 minutes (CPT code G0156).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for inpatient hospital services provided from August 30, 2021, to September 2, 2021.  You asked the Plan to waive the copayment for the inpatient hospital services. You say that the bill does not make sense since you did not stay in the hospital. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $200 per day for days 1-4 and $0 per day after day 4 for each inpatient stay.   The file shows that you were in the hospital from August 30, 2021, to September 2, 2021, but there is no copayment for the discharge date. Therefore, you have been asked to pay $200 per day for the first 3 days of inpatient hospital services. The total for your stay is $600 ($200 copayment x 3 days = $600). The inpatient hospital services fall within the Inpatient Hospital Care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital services provided from August 30, 2021, to September 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve two surgical placements of implant bodies: endosteal implants (D6010 x2).  You asked the Plan to pre-approve the endosteal implants. You say that you feel this denial should be overturned due to the lack of communication between the Plan and the provider. The Plan denied your request. The Plan says this service is not covered under your benefit 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-approve two surgical placements of implant bodies: endosteal implants (D6010 x2).
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. You say that the enrollee has had a severe decline in function following acute hospitalization and the enrollee is continuing to decline in health. The Plan denied your request. The Plan says the stay is not medically necessary based on IRF criteria.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.  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 conse enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for frequent falls. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  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 IRF admission and services.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on October 15, 2021.  You asked the Plan to waive the copayment for the ER visit. You say that the services were medically necessary. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 copayment for each emergency room visit.   You have been asked to pay a $90 copayment for the ER visit. The ER visit falls within the Emergency Care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on October 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the over-bed table (E0274).  You asked the Plan to pre-approve the over-bed table. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says this item is 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 item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve the over-bed table (E0274).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve wheelchair van transportation (A0130) and stretcher van transportation (T2005).  You asked the Plan to pre-approve wheelchair van transportation and stretcher van transportation. The Plan denied your request. The Plan says routine transportation is when you travel in a vehicle that is not an ambulance (such as a van or mini bus). The Plan also says that your health plan benefit for transportation services does not cover routine transportation using a stretcher.   Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The routine transportation benefit does not cover transportation by stretcher.  We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve wheelchair van transportation (A0130) and stretcher van transportation (T2005).
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve ambulance transport from the enrollee's home to the dermatologist's office.  You asked the Plan to pre-approve ambulance transport from the enrollee's home to the dermatologist's office. The Plan denied your request. The Plan says that the Plan requires the provider to document in the medical record that the enrollee is bed bound and unable to get up from bed, unable to walk and unable to sit in a chair including a wheelchair. Review of the medical record did not show that the enrollee is bed bound and unable to get out of bed.  The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when they meet certain origin and destination requirements. A doctor's office is not a covered destination.   The services you have asked the Plan to pre-approve are ambulance transport services to a doctor's office. Therefore, we decided that the Plan does not have to pre-approve ambulance transport from your home to your dermatologist's office.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve gingival irrigations (D4921) for the upper left, upper right, lower left, and lower right quadrants.  You asked the Plan to pre-approve the gingival irrigations. The Plan denied your request. The Plan says this service is not a covered 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 pre-approve gingival irrigations (D4921) for the upper left, upper right, lower left, and lower right quadrants.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve removal of intact breast implant (19328).  You asked the Plan to pre-approve removal of intact breast implant. You say that the removal of intact breast implant is medically necessary. The Plan denied your request. The Plan says the removal of intact breast implant is not medically necessary because the records show the enrollee does not have painful contracture of the right breast nor evidence of granulomas, infection, implant extrusion or leakage.  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 removal of intact breast implant. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that the right implant has broken or failed, is infected, or there is implant extrusion, siliconoma, granuloma, painful capsular contracture, or interference with a diagnosis of breast cancer.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of removal of intact breast implant have not been met. Therefore, we decided that the Plan does not have to pre-approve removal of intact breast implant (19328).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an expandable controller with harness, electronic connection, and joystick remote replacement.  You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.  The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The rules say that an expandable controller and harness are used to control multiple power options.  The requested joystick remote replacement does not serve a purpose that is primarily medical in nature. The expandable controller with harness and electronic connection are not needed to control the approved power options. Therefore, we decided that the Plan does not have to pre-approve an expandable controller with harness, electronic connection, and joystick remote replacement.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for surgical supplies (A4550) provided June 16, 2021.  You asked the Plan to pay for the surgical supplies. You say that the services were medically necessary. The Plan denied your request. The Plan says the code billed is not separately payable.  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 A4550 is not supported in the medical record. Specifically, per the National Physician Fee Schedule this code has a status of "B" and is not separately payable. Based on this information, we decided that Medicare rules for coverage of the surgical supplies have not been met. Therefore, we decided that the Plan does not have to pay for surgical supplies (A4550) provided June 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve walk-in shower conversion (A9900).  You asked the Plan to pre-approve walk-in shower conversion. You say that you are unable to use a conventional bathtub due to instability of your knees. For safety concerns you had no option other than replacing your old shower. The Plan denied your request. The Plan says this item is 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 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 walk-in shower conversion (A9900).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a power recliner chair (E1399).  You asked the Plan to pre-approve a recliner chair. You say that you need the medical recliner chair, and you would like to appeal the denial. The Plan denied your request. The Plan says a power recliner is not considered medical in nature and is useful to a person in the absence of illness or injury.  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 a power recliner chair (E1399).
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered by the out-of-network (OON) provider on October 1, 2021.  You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were 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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered by the out-of-network (OON) provider on October 1, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Entresto for the enrollee.  You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered under Part B.  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 pre-approve Entresto for the enrollee.   Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Freestyle test strips.  You asked the Plan to pre-approve the freestyle test strips. You say that the item is medically necessary. The Plan denied your request. The Plan says plan preferred products must be used.  The Plan must follow Medicare rules. Medicare rules say that MA plans may specify brands and manufacturers as preferred and charge lower cost-sharing for the preferred brands or may limit the Durable Medical Equipment (DME) to only those preferred brands and manufacturers.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the freestyle test strips have not been met. Specifically, no medical records were submitted indicating the requested item is medically necessary over the preferred brands. Therefore, we decided that the Plan does not have to pre-approve the Freestyle test strips.
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. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary based on IRF criteria. The Plan states you can safely receive the services you need in other settings, for example: a skilled nursing facility or home with home health and home physical therapy.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.  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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for surgical repair of a hip fracture after a fall and was treated for gastrointestinal bleeding post-operatively. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve compression stockings identified with code A6530 and A6545.  You asked the Plan to pre-approve the compression stockings. You say that the items are medically necessary. The Plan denied your request. The Plan says these are not covered items.  The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 and A6545 are noncovered because they do not meet the statutory definition of a surgical dressing.   Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6530 and A6545.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the air purifier, purchased on December 18, 2020.   You asked the Plan to pay for this air purifier. You say that your doctor stated an air purifier was necessary for you. The Plan denied your request. The Plan says air purifiers are not covered by Medicare under any circumstance.  The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The rules specifically state air cleaners or air purifiers are not covered. While it is understood this item may be beneficial for your use, this type of equipment is not covered by the Plan or by Medicare.  Therefore, we decided that the Plan does not have to pay for the air Purifier, purchased on December 18, 2020.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a BRCA multigene panel.  You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.  The Plan must follow Medicare rules. Medicare rules say that a BRCA multigene panel is covered when specific criteria are met.  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 services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records do not support that the enrollee has triple negative breast cancer (estrogen receptor negative, progesterone receptor negative, and human epidermal growth factor receptor 2 negative) diagnosed at or before 60 years of age. The records do not support that the criteria for coverage are met; therefore, the testing is not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a BRCA multigene panel.