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

We decided that the Plan does not have to pay for the shoe insert (foot orthotic) you received on July 29, 2021.
You asked the Plan to pay for the foot orthotic. You say that this was not a diabetic foot insert, but a insert for a medical boot brace you have. You stated that this sole insert is a cushion because o a sore callus on the bottom of your foot. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease. While you do have a leg brace, this insert is not an integral part of the shoe itself that is attached to that brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pay for the shoe insert (foot orthotic) you received on July 29, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care provided on March 10, 2021.
You asked the Plan to pay for the critical care. You say that the correct code was assigned, and no coding changes are required. You say that the level of service is considered medically necessary, and the medical records support the claim as originally submitted. The Plan denied your request. The Plan says the documentation does not support a critical care visit of 30-74 minutes was performed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99291 is critical care, evaluation, and management of the critically ill or critically injured patient; first 30-74 minutes.
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the critical care. Our reviewer says that the submitted documentation was reviewed and does not meet criteria for coverage. Our reviewer found that critical care services do not document time spent performing critical care, and therefore cannot be confirmed. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the critical care have not been met. Therefore, we decided that the Plan does not have to pay for the critical care provided on March 10, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Truxima for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says there is no compendia support for this drug for interstitial lung disease.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 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 drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found based on the medical records provided and the Medicare-approved major drug compendia there is no documentation that the Truxima meets Medicare criteria for medically reasonable and necessary for the patient. The Medicare-approved major drug compendia do not cite interstitial lung disease as a medically-accepted indication for this drug. 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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Truxima for the enrollee
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the Vitamin D assay lab test you received
on June 23, 2021.
You asked the Plan to waive the copayment for the lab test. You say that your doctor ordered the wrong test for
you, so you shouldn't have a copayment. The Plan denied your request. The Plan says you were charged this
copayment 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 a $15
copayment for [Enter category in plan contract from which cost sharing was applied].
You have been asked to pay a $15 copayment for the lab test. 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 Vitamin D assay lab test you received on June 23, 2021.
Your complaint about the provider ordering the wrong lab test is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 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 considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found you do not need intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. While you may benefit from continued physical therapy, and occupational therapy, your rehab needs can be safely provided in an alternate and low intensity setting such as in a skilled nursing facility. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an exit and entrance ramp.
You asked the Plan to pre-approve the ramp. You say that this ramp is needed to get into and out of the house. The Plan denied your request. The Plan says there are no detailed drawings or detailed notes indicating where the ramps will be used in relation to the stair lift.
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 the ramp. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that the requested ramp will be safe and effective for your condition. There is no evidence of objective physical specific details of the home showing where the ramp will be placed. There is no evidence indicating that your needs are unable to be met with the current stair lift and without this ramp. The ramp is not medically necessary for the diagnosis or treatment of your condition or to improve the function of a malformed body member. 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 ramp have not been met. Therefore, we decided that the Plan does not have to pre-approve an exit and entrance ramp.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to waive the deductible for laboratory services (88305, 88312) provided by an out-of-network provider on August 4, 2021.  You asked the Plan to waive the deductible for laboratory services. You say that the enrollee was referred by an in-network provider. The Plan denied your request. The Plan says this processed correctly.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $1000 deductible which applies to most out-of-network services.   The item or service you asked the Plan to waive the deductible for was provided by an out-of-network provider. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1000 deductible which applies to most out-of-network services. This cost sharing is a contractual obligation that had not been met at the time laboratory services was received on August 4, 2021. Therefore, we decided that the Plan does not have to waive the deductible for laboratory services (88305, 88312) provided by an out-of-network provider on August 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the electronic connection (E2311), power seating system (E1007), manual swingaway (E1028), leg rest (E1012), and headrest (E0955).
You asked the Plan to pre-approve the power wheelchair accessories.. You say that the items are medically necessary. The Plan denied your request. The Plan says the items are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that items 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 the power wheelchair accessories. Our reviewer says that the items are not medically necessary. Our physician reviewer found the documentation does not reveal that the patient needs are at high risk for development of a pressure ulcer or utilizes intermittent catheterization for bladder management or needs a power seating system to manage increased tone or spasticity. The documentation does not reveal that tilt and recline are medically necessary therefore the request for the retractable hardware and headrest options are not medically necessary. There is no evidence in the submitted documentation of edema, knee casting or bracing that requires power elevating leg rests and the E2311 is not medically necessary as the patient does not require multiple power options. 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 power wheelchair accessories. have not been met. Therefore, we decided that the Plan does not have to pre-approve the electronic connection (E2311), power seating system (E1007), manual swingaway (E1028), leg rest (E1012), and headrest (E0955).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided on June 15, 2021, to June
17, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the home health services. You say that the servicesweres medically necessary.
The Plan denied your request. The Plan says services must be obtained through an in-network provider to be
covered.
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 the home health services provided on June 15,
2021, to June 17, 2021 by an out-of-network (OON) provider
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the re-cement crown (D2920), provided on September 2,
2021.
You asked the Plan to pay for the re-cement crown. You say that the service was medically necessary. The Plan
denied your request. The Plan says this is not a covered service.
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. Specifically, the service is not listed in the Plan's benefit chart. This
means the service is not covered. Therefore, we decided that the Plan does not have to pay for the re-cement
crown (D2920), provided on September 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital admission and services provided from July 10, 2021, to July 18, 2021.
You asked the Plan to waive the copayment for the inpatient stay. You say that the enrollee was transferred from one hospital facility directly to another. This was one inpatient stay and only the one copayment should apply. The Plan denied your request. The Plan says this claim was processed correctly, and the enrollee's copayment was assessed in accordance with the contract. Inpatient cost sharing applies each time the enrollee is admitted to the hospital, including transfer to a different facility or different level of inpatient care.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $450 copayment for each of the first four days of an inpatient stay. There is a $0 copayment for additional Medicare-covered days. For inpatient hospital care, the cost-sharing described applies each time the enrollee is admitted to the hospital. The enrollee has been asked to pay a $1,800 copayment for the inpatient stay which exceeded four days ($450 x 4 = $1,800). The enrollee was transferred and admitted to a new facility on July 10, 2021. Therefore, a new and separate cost-sharing applies. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient hospital admission and services provided from July 10, 2021, to July 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the office visits (99211, 99213) provided on January 20, 2021 and August 17, 2021.
You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayments have 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 $40 copayment for services obtained from a specialist, or under certain circumstances, treatment by a nurse practitioner or physician's assistant or other non-physician health care professionals in a specialist's office. Some telehealth services including consultation, diagnosis, and treatment by a physician or practitioner, for patients in certain rural areas or other places approved by Medicare are covered. You would have the same cost-sharing that applies to specialist services. You pay these amounts until you reach the out-of-pocket maximum. You have been asked to pay $49.31 ($40 + $9.31) for the telehealth office visits provided by a specialist. This amount includes the copayment of $40 for date of service January 20, 2021. Additionally, this amount includes the Plan allowed amount of $9.31 for date of service August 17, 2021, which is less than the applicable copayment. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the office visits (99211, 99213) provided on January 20, 2021 and August 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet
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 considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found you do not need intensive therapies, consisting of at least 3 hours of therapy per day
at least 5 days per week with multidisciplinary approach to daily therapy. While you may benefit from
continued physical therapy, and occupational therapy, your rehab needs can be safely provided in an alternate
and low intensity setting such as in home with aide services and continued therapies.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids (V5264, V5298) purchased on August 9, 2021, from an out-of-network provider.
You asked the Plan to pay for the hearing aids. You say that you chose these hearing aids because they were very highly rated and were cheaper than those offered by the Plan. You thought this was a better option that would save yourself and the Plan money. The Plan denied your request. The Plan says supplemental hearing services provided outside of the specified vendor network are not covered. The provider in question is not part of this network.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when they are purchased through the Plan's specified hearing vendor network. We looked at the file and the Plan's rules. The provider in this case is not part of the Plan's routine hearing vendor network. Based on this information, we decided that the Plan's rules for coverage of the hearing aids
have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids (V5264, V5298) purchased on August 9, 2021, from an out-of-network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
You asked the Plan to pre-approve the admission. You say that the enrollee would benefit from skilled therapy services in an inpatient setting with medical monitoring. The Plan denied your request. The Plan says this 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 pre-approve the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the documentation is not clear that the enrollee is medically stable for a SNF admission, or requires skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF. The documentation does not reveal that at this time the enrollee's functional level requires skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee does not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF at this time. As a practical matter this enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility setting at this time. 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an oral surgery evaluation to be rendered by an out-of-network (OON) provider.
You asked the Plan to pre-approve the oral surgery evaluation. The Plan denied your request. The Plan says the drainage from the implants appears to be isolated from the enrollee's sinuses, entirely dental, and not a covered service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the oral surgery evaluation when the services are medically necessary and reasonable.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the oral surgery evaluation. Our reviewer says that this service does not meet the criteria for coverage to be rendered by an out-of-network (OON) provider. Our physician reviewer found the removal of the infected implants and teeth appear to be an independent issue to the sinus and an in-network provider with proper dental credentials as an oral surgeon would be appropriate at this time and no need for an OON provider. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the oral surgery evaluation have not been met. Therefore, we decided that the Plan does not have to pre-approve an oral surgery evaluation to be rendered by an out-of-network (OON) provider.