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

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (K0861) and accessories (E1028, E2361, E2300).
You asked the Plan to pre-approve a Group 3 power wheelchair and accessories. You say that this is necessary because the enrollee has arthritis. The Plan denied your request. The Plan says this is not covered for the enrollee's condition.
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for enrollees who have a mobility limitation that is due to: 1. A neurological condition; 2. Myopathy; or
3. Congenital skeletal deformity. The file does not show that the enrollee has a mobility limitation that is due to a neurological condition, myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair (K0861) and accessories (E1028, E2361, E2300).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the implant placements, bone graft and extraction.
You asked the Plan to pre-approve the implant placements, bone graft and extraction. You say that you want to
eat properly and not choke using your dentures. The Plan denied your request. The Plan says the services are
not covered benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the
implant placements, bone graft and extraction.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for urgent care services you received on December 23, 2020.

You asked the Plan to waive the copayment for the urgent care services. You say that you cannot afford this 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 $55 copayment for urgent care services.

You have been asked to pay a $55 copayment for the urgent care services. 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 urgent care services you received on December 23, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a mileage exception for routine transportation.
You asked the Plan to provide coverage for a mileage exception for routine transportation. You say that you need an exception to the routine transportation mile limit for an appointment. The Plan denied your request. The Plan says exceptions are not made to supplemental benefits. You are requesting an additional 35 miles one way for a total of 85 miles. Your benefit only allows 50 miles one way.
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 Plan covers routine transportation up to 50 miles one way only. Exceptions are not made to supplemental benefits. Therefore, we decided that the Plan does not have to provide coverage for a mileage exception for routine transportation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a commode chair (E0163), a patient lift (E0630), and an extra heavy-duty wheelchair (K0007).
You asked the Plan to pre-approve a commode chair, a patient lift, and an extra heavy-duty wheelchair. You say that the requested items are a medical necessity for you. The Plan denied your request. The Plan says rules for coverage for the requested items have not been met.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. The provided medical documentation does not address the coverage criteria for a commode chair, a patient lift, and an extra heavy-duty wheelchair. Based on the available documentation, we decided that Medicare rules for coverage of a commode chair, a patient lift, and an extra heavy-duty wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a commode chair (E0163), a patient lift (E0630), and an extra heavy-duty wheelchair (K0007).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services with the billing of diagnosis related group (DRG) 871 provided from March 20, 2020 to March 23, 2020.
You asked the Plan to pay for the inpatient hospital services. You say that the medical records support the billing of the principal diagnosis code A41.9: sepsis, unspecified organism with DRG 871. The Plan denied your request. The Plan says the medical records do not support the billing of the principal diagnosis code A41.9: sepsis, unspecified organism with DRG 871.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services provided with principal diagnosis code A41.9. 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 the inpatient hospital services. Our reviewer says that the medical records do not support the billing of the principal diagnosis code A41.9: sepsis, unspecified organism with DRG 871. Our physician reviewer found the reviewed documentation supported an admission for Pneumonia, unspecified organism. The documentation was inconsistent/unclear regarding a diagnosis of sepsis. Even though sepsis is documented on H&P, progress notes and discharge summary, supporting medical record documentation was not found within the record. Member presented with nausea and vomiting. Appeal letter notes tachycardia, leukocytosis and tachypnea. There was no clinical or laboratory evidence of sepsis. The review has determined that the records did not support the billing of DRG 871 with principal diagnosis code A41.9: sepsis, unspecified organism. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services with the billing of diagnosis related group (DRG) 871 provided from March 20, 2020 to March 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a back-up battery for CPAP machine (A9270).
You asked the Plan to pre-approve a back-up battery. You say that you need a backup batter to be used during electrical power outages. The Plan denied your request. The Plan says Medicare does not allow payment for power generators or alternative power sources needed in the event of power outages.
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 back-up battery for CPAP machine (A9270).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the UV and anti-reflective coating for lenses provided on July 26, 2021.
You asked the Plan to pay for the UV and anti-reflective coating. You say that you must wear corrective lenses to drive because your eyes are sensitive. You say that your doctor prescribed these lenses, and they should be approved. The Plan denied your request. The Plan says the services are not covered benefits.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the UV and anti-reflective coating have not been met. Specifically, lens upgrades are not covered. Therefore, we decided that the Plan does not have to pay for the UV and anti-reflective coating for lenses provided on July 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0676).
You asked the Plan to pre-approve a pneumatic compression device. You say that this is medically necessary. The Plan denied your request. The Plan says this device is statutorily denied.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0676).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on December 3, 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 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 must 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 physician services provided to the enrollee on December 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial lower denture with resin base (D5212).

You asked the Plan to pre-approve the dental item. You say that you had a previous approval for a lower denture. You say that you were not able to use the previously approved authorization. You also say that without a partial lower denture, you are having difficulty eating. The Plan denied your request. The Plan says partial lower denture with resin base is not listed as 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 partial lower denture is not among those covered under this benefit. Additionally, the record shows that the previous authorization was approved while you were enrolled in a different plan. Therefore, we decided that the Plan does not have to pre-approve a partial lower denture with resin base (D5212).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on May 24, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the enrollee's primary insurer must process the claim first.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer.
However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the provider to bill the primary insurer. As the secondary insurer, the Plan cannot be held responsible for the services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the services provided on May 24, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (87481, 87798, 88305, 88312, 88313) rendered by the out-of-network (OON) provider on May 18, 2020.

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 (87481, 87798, 88305, 88312, 88313) rendered by the out-of-network (OON) provider on May 18, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a uvulopalatopharyngoplasty procedure to be provided by an out-of-network provider.

You asked the Plan to pre-approve a uvulopalatopharyngoplasty. You say that only the requested out-of-network provider is capable of providing you with the necessary care. The Plan denied your request. The Plan says rules for out-of-network care have not been met.

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 a uvulopalatopharyngoplasty. Our reviewer says that out-of-network care is not medically reasonable and necessary in this case. Our physician reviewer found that the record indicates that you have a history obstructive sleep apnea. The record indicates that you have been recommended for a surgical procedure. The Plan has indicated that the service is available in network.

The record does not indicate that in-network coverage is unavailable or inadequate to meet your medical needs. The elements of the coverage criteria are not satisfied. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a uvulopalatopharyngoplasty 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 a uvulopalatopharyngoplasty. Therefore, we decided that the Plan does not have to pre-approve a uvulopalatopharyngoplasty procedure to be provided by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve surgery for an aneurysm repair.
You asked the Plan to pre-approve surgery for an aneurysm repair. You say that the services are necessary. The Plan denied your request. The Plan says that medical necessity has not been established. Therefore, coverage criteria have not been met.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically 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 surgery for an aneurysm repair. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the documentation supports the medical necessity of the procedure in question. Additionally, if out of network care is an issue (as suggested by the materials provided), the documentation supports coverage of out of network services. This enrollee has a very large aneurysm of the splenic artery documented to be 4.7 x 5 cm. This is extremely large as splenic aneurysms go and timely treatment is recommended to prevent life threatening rupture. While this may not require repair within 24 hours, for the purposes of this determination it should be considered an emergency in that the potential delay to seek another provider in network is prohibitive. The treatment plan articulated by the provider is both reasonable and 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 surgery for an aneurysm repair have been met. Therefore, we decided that the Plan has to pre-approve surgery for an aneurysm repair.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transit kit and positioning back cushion.
You asked the Plan to pre-approve a transit kit and positioning back cushion. You say that this wheelchair and accessories are medically necessary. The Plan denied your request. The Plan says while the wheelchair and Medicare allowed accessories were approved, the transit kit and positioning cushion are not covered by Medicare.
The Plan must follow Medicare rules. Medicare does not pay for equipment that is not shown to be necessary. The transport kit and positioning back cushion are convenience items and are not covered. Therefore, we decided that the Plan does not have to pre-approve a transit kit and positioning back cushion.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided the Plan does not have to pre-approve a new manual wheelchair and accessories for the enrollee.
You asked the Plan to pre-approve this equipment. You say that the current wheelchair needs preplacement
because it needs repair and the enrollee lost 50 pounds. The Plan denied your request. The Plan says the current
wheelchair is only 3 years old and there is no indication from a durable medical equipment vendor that the
equipment is beyond repair or cannot be adjusted to accommodate the enrollee's weight loss.
The Plan must follow Medicare rules. The rules say that the reasonable useful lifetime of durable medical
equipment is determined through program instructions. In the absence of program instructions, carriers may
determine the reasonable useful lifetime of equipment, but in no case can it be less than 5 years. The file shows
that the enrollee has had this equipment less than 5 years. There is no documentation to show the current
equipment cannot be repaired and adjusted to meet the enrollee's needs. Therefore, we decided that the Plan
does not have to pre-approve a new manual wheelchair and accessories for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids (V5160, V5261) provided on June 11, 2021.
You asked the Plan to pay for hearing aids. You say that you will not provide the hearing aids until this claim is paid. The Plan denied your request. The Plan says there is not a proof of delivery for the items at issue.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid proof of delivery for the supplies provided in this case. The records indicate that the items have not been provided yet. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for hearing aids (V5160, V5261) provided on June 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for durable medical equipment provided to the enrollee on May 12, 2020.
You asked the Plan to pay for the durable medical equipment. You say that this claim should be reconsidered due to medical necessity. The Plan denied your request. The Plan says you file this claim outside of the allowable timeframe.
The Plan must follow Medicare rules. Medicare rules say that claims must be filed within 1 calendar year of the date of service. In this case, the date of service was May 12, 2020. You did not file this claim with the Plan until May 14, 2021, after this 1 calendar year period had ended. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the durable medical equipment have not been met. Therefore, we decided that the Plan does not have to pay for durable medical equipment provided to the enrollee on May 12, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Cxbladder Monitor test (0012M) provided on April 23,
2021.
You asked the Plan to pay for the Cxbladder Monitor test (0012M). You say that you would like the Plan to
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that CPT codes 0012M and 0013M for Cxbladder
testing are non-covered.
We looked at the file and Medicare rules. The service at issue is non-covered. Therefore, we decided that the
Plan does not have to pay for the Cxbladder Monitor test (0012M) provided on April 23, 2021.