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

We decided that the Plan does not have to pre-approve a bathtub rail.
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 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 bathtub rail.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (87640, 87498, 87496, 87532, 87798) provided January 1, 2021.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the service at issue is non-covered.
The Plan must follow Medicare rules. Medicare rules say that Multiplex PCR respiratory viral panels of 6 or more pathogens are non-covered. We looked at the file and Medicare rules. The testing at issue was for 6 or more pathogens. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (87640, 87498, 87496, 87532, 87798) provided January 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an infrared thermometer.
You asked the Plan to pre-approve an infrared thermometer. You say that the requested item will allow you to monitor your health by yourself. The Plan denied your request. The Plan says the requested item is not covered by Medicare or under your contract.
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 an infrared thermometer.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the routine electrocardiogram (EKG) screening (G0403) provided on April 27, 2021.
You asked the Plan to waive the copayment for the EKG screening. You say that this was part of your annual wellness visit and should be included with no copayment required. The Plan denied your request. The Plan says this is a service that is not included in the annual wellness visit. Therefore, a copayment applies.
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 $10 copayment for other Medicare-covered outpatient diagnostic tests. There is no coinsurance, copayment, or deductible for the annual wellness visit. If you receive services that address a medical condition during the same office visit, additional cost-share may apply.
You have been asked to pay a $10 copayment for the EKG screening. The EKG screening was provided at the time of an annual wellness visit but is not included as one of the services. According to the Centers for Medicare and Medicaid Services (CMS) Medicare Learning Network, a routine EKG, described with code G0403, G0404, or G0405, may be provided at the time of an initial preventative physical exam (also known as a welcome to Medicare preventative visit) which is provided within the first 12 months of the first Medicare Part B coverage period. If G0403, G0404, or G0405 are performed at the time of this visit, a copayment or coinsurance and deductible apply. This service is not listed as being included as part of an annual wellness visit.
An EKG falls into the outpatient diagnostic tests benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the routine electrocardiogram (EKG) screening (G0403) provided on April 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910) and localized delivery of antimicrobial agents (D4381) provided on May 20, 2021.
You asked the Plan to pay for the periodontal maintenance and localized delivery of antimicrobial agents. You say that you have a $1,000 allowance per year to cover dental care according to your Plan. You also say that the periodontal maintenance provided was nothing more than a routine cleaning and was covered by your previous insurance provider. The Plan denied your request. The Plan says these services are 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 (D4910) and localized delivery of antimicrobial agents (D4381) provided on May 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910) and preventive procedure (D1999) provided on May 24, 2021.
You asked the Plan to pay for the periodontal maintenance and preventive procedure. You say that you were supposed to have a basic cleaning which would be no charge, and no x-rays were taken. You also say that you do not have the money to pay this bill. The Plan denied your request. The Plan says these services are not covered. The Plan also says that you did not contact the Plan prior to the date of service to verify benefits and provider eligibility.
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 (D4910) and preventive procedure (D1999) provided on May 24, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Botox injection provided on May 18, 2021.
You asked the Plan to waive the coinsurance for the Botox injection. You say that you called the cost estimate line prior to scheduling the appointment and were told the out-of-pocket cost would be $45. You say that you paid $45 at the appointment but was surprised to get an additional bill. The Plan denied your request. The Plan says the coinsurance applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% for each Medicare-covered Part B drug obtained at an in-network provider's office or outpatient setting.
You have been asked to pay $242.40, which is 20% of the allowed amount for the Botox injection. The allowed amount is $1,212 (20% x $1,212 = $242.40). The Botox injection falls within the "Medicare Part B prescription drugs" 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 coinsurance for the Botox injection provided on May 18, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for continuation of skilled nursing facility (SNF) services
provided from May 2, 2021, through May 31, 2021.

You asked the Plan to pay for continuation of SNF services. The Plan denied your request. The Plan says
continuation of SNF services is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is 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 pay for continuation of SNF services. Our reviewer
says that daily skilled services are not medically necessary. Our physician reviewer found that from a nursing
perspective, the enrollee received oral and topical medications. The enrollee was monitored for borderline low
blood pressure. She was treated for knee pain. She had routine foley catheter care. Regarding rehabilitation
services, the enrollee received physical therapy and occupational therapy in the SNF. By the dates in question,
the enrollee was at contact guard assist level with functional mobility including gait to 5 feet. The enrollee
required varying assist with activities of daily living. The enrollee worked with speech therapy on cognitive
linguistic deficits. There are no identifiable skilled nursing service needs. There are no identifiable skilled
therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. As a
practical matter, this enrollee does not meet severity of illness or intensity of service criteria for an inpatient
basis in a skilled nursing facility setting.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of continuation of SNF services have not been met. Therefore, we decided that the
Plan does not have to pay for continuation of SNF services provided from May 2, 2021, through May 31, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Volara respiratory system.
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your request. The Plan says none of the covered conditions are present.
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases. 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 system. Our reviewer says that the requested system is not medically reasonable or necessary. Our physician reviewer found there is no evidence of cystic fibrosis, bronchiectasis, or neuromuscular disease. You have a dry cough, but the medical record does not document difficulty clearing secretions. This system provides airway pressure oscillation, expiratory
positive pressure for lung expansion, and nebulizer therapy. None of these treatments appears necessary for you, and there is no convincing evidence that this system is effective in the treatment of pulmonary disease, or in unilateral weakness of the diaphragm. 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 system have not been met. Therefore, we decided that the Plan does not have to pre-approve a Volara respiratory system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Freestyle Libre 14-Day Sensors (K0553).
You asked the Plan to pre-approve Freestyle Libre 14-Day Sensors. You say that the item is medically
necessary. The Plan denied your request. The Plan says you do not use insulin to treat your diabetes.
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 use insulin
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of
Freestyle Libre 14-Day Sensors have not been met. Therefore, we decided that the Plan does not have to preapprove
Freestyle Libre 14-Day Sensors (K0553).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve alcohol wipes.
You asked the Plan to pre-approve the wipes. You say that this is necessary for my health. The Plan denied your request. The Plan says these items are not required for the proper functioning of the device.
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 alcohol wipes.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transit system frame options.
You asked the Plan to pre-approve the transit system frame options. You say that the enrollee's medical conditions support the need for the item in dispute. The Plan denied your request. The Plan says the Medicare rules for coverage have not been met for the requested item.
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 transit system frame options.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional periapical x-ray (D0230), oral or facial
photographic image (D0350), and topical application of fluoride varnish (D1206) provided on April 29, 2021.
You asked the Plan to pay for the dental services. You say that you went for a cleaning and a check-up. You
say that you approved the fluoride treatment, but you did not approve any other extras. You say that they broke
a filling when they were cleaning your teeth. You also say that you switched dentists because you did not trust
your previous one. The Plan denied your request. The Plan says 1 periapical x-ray is covered per calendar year.
The Plan says that the frequency limit has been exceeded. The Plan also says that the oral or facial
photographic image and topical application of fluoride varnish are not listed as covered services.
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 and periapical x-ray is listed as
covered, the frequency limit has been exceeded. The record shows that the Plan paid for the initial periapical xray
that you received on the date of service in this case. Additionally, the oral or facial photographic image and
fluoride varnish application are not among those covered under this benefit. Therefore, we decided that the
Plan does not have to pay for the additional periapical x-ray (D0230), oral or facial photographic image
(D0350), and topical application of fluoride varnish (D1206) provided on April 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1392).
You asked the Plan to pre-approve a portable oxygen concentrator. You say that your current device does not last long and are in need of another. The Plan denied your request. The Plan says you already have a device that serves the same purpose as the device requested.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The file shows that you have a portable oxygen tank (E0431). a portable oxygen tank (E0431) serves the same purpose as a portable oxygen concentrator. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1392).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One.
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 step therapy requirement is not met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications. 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 enrollee has bilateral primary osteoarthritis of the knee. He has not tried the Plan's required drugs, Gel-One and Euflexxa. The records do not show that the required drugs would be contraindicated or less effective; therefore, Synvisc-One 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 Synvisc-One.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport provided on April 13, 2021.
You asked the Plan to pay for ambulance service, basic life support, non-emergency transport. You say that the ambulance transport was medically necessary. The Plan denied your request. The Plan says ambulance transport to or from a doctor's office for a scheduled appointment is not a Medicare-covered benefit.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 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 ambulance service, basic life support, non-emergency transport. Our reviewer says that the ambulance transport was not medically necessary. Our physician reviewer found that the documentation does not support that other means of transport (such as stretcher van) were contraindicated for this enrollee. The documentation does not support that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully equipped
ambulance can provide for safe transport. The transportation was not urgent and did not require any treatment. The documentation does not support that the ambulance transport on April 13, 2021 was medically reasonable and necessary for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ambulance service, basic life support, non-emergency transport have not been met. Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport (A0428, A0425) provided on April 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a Botox injection provided on May 18, 2021.
You asked the Plan to waive the copayment for a Botox injection. You say that you disagree with the additional copayment because you only saw one physician. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 20% coinsurance for Medicare covered Part B drugs self-administered or administered through home infusion equipment, and a $15 copayment for the total cost of Part B drugs purchased at a pharmacy, administered by a pharmacist, or administered by a health care professional.
You have been asked to pay a $15 copayment for a Botox injection. A Botox injection falls within the Medicare Part B prescription drugs 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 a Botox injection provided on May 18, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional skilled nursing visits.
You asked the Plan to pre-approve the additional skilled nursing visits. The Plan denied your request. The Plan says the documentation does not support the condition is such that the services need a registered nurse, or the condition is unstable.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the additional skilled nursing visits. Our reviewer says that the additional skilled nursing visits are not medically reasonable and necessary for the enrollee. Our physician reviewer found the enrollee has a bladder catheter, which requires monthly changing. While the enrollee previously had hematuria, there is no evidence that hematuria is ongoing, or that it is causing issues requiring frequent evaluation/troubleshooting. Our reviewer also found that there is no documentation of other skilled nursing needs. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the additional skilled nursing visits have not been met. Therefore, we decided that the Plan does not have to pre-approve additional skilled nursing visits.