Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services provided to you from February 3,
2021, to June 15, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider is not
enrolled in Medicare.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is
not enrolled in the Medicare program.
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare
program. Therefore, we decided that the Plan does not have to pay for the psychotherapy services provided to
you from February 3, 2021, to June 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a facet joint injection.
You asked the Plan to pre-approve facet joint injection. You say that the enrollee has suffered severe persistent pain despite prolonged courses of conservative therapy. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the enrollee has not had pain/impaired function for at least 3 months.
The Plan follows Medicare rules. Medicare rules state that facet joint interventions may be covered for certain clinical indications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve facet joint injection. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested facet joint injection. Our physician reviewer found the records do not document that the enrollee has had pain and impaired function for at least 3 months. In addition, the enrollee has radiculopathy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of facet joint injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a facet joint injection.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Nurtec ODT.
You asked the Plan to pre-approve Nurtec ODT. The Plan denied your request. The Plan says this is not covered under the enrollee's plan.
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 Nurtec ODT.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a combination skin protection and positioning cushion for a wheelchair.
You asked the Plan to pre-approve combination skin protection and positioning cushion. You say that you are appealing this denial. The Plan denied your request. The Plan says you do not meet the criteria for a combination skin protection and positioning seat cushion.
The Plan follows Medicare rules. Medicare rules state that a combination skin protection and positioning seat cushion may be covered for enrollees who meet the criteria for both a skin protection seat cushion and a positioning seat cushion. 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 combination skin protection and positioning cushion. Our reviewer says that you do not meet the Medicare criteria for this combination skin protection and positioning cushion. Our physician reviewer found you do not have significant postural asymmetries due to a covered diagnosis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of combination skin protection and positioning cushion have not been met. Therefore, we decided that the Plan does not have to pre-approve a combination skin protection and positioning cushion for a wheelchair.
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 IRF care is medically necessary for this enrollee. The Plan denied your request. The Plan says the criteria for an IRF are not met. The enrollee's care needs can be met in a less intensive setting.
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 based on the provided medical records, the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does require physical and occupational therapy services but does not require an intensive rehabilitation therapy program. There is concern that the enrollee will not be able to fully participate in and benefit from the intensive therapy program provided in an IRF due to their level of weakness and fatigue with therapy. Care at a skilled nursing facility level appears to be more appropriate in this case. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 12 acupuncture visits.
You asked the Plan to pre-approve the acupuncture services. You say that based on medical necessity you have to go out of network. The Plan denied your request. The Plan says the enrollee does not have a diagnosis of chronic low back pain. Therefore, the requested service is not covered per the Plan benefits.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case. We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, the Plan covers acupuncture for chronic low back pain. You do not have a diagnosis of chronic low back pain. Therefore, we decided that the Plan does not have to pre-approve 12 acupuncture visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation feature (E2300).
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says this is not medically necessary and 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 power seat elevation feature (E2300).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox.
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 Botox is covered for specific indications only. 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 show that you have a diagnosis of gastroparesis. This is not a condition for which Botox is covered by the Medicare criteria. There is no documentation that you have a covered indication for Botox. The services are therefore 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 Botox.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for podiatry services provided on April 2, 2021, by an OON
provider.
You asked the Plan to pay for podiatry services. You say that you called and verified that your doctor took your
insurance. The Plan denied your request. The Plan says prior authorization was not obtained by the member's
primary care physician. The Plan says that there are in-network providers available to provide these services.
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 podiatry services provided on April 2, 2021, by an
OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for DME and related supplies provided from
March 22, 2021, to April 22, 2021.
You asked the Plan to waive the coinsurance for DME and related supplies. You say that you disagree with the
charges. 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 DME and related supplies.
You received DME and related supplies on March 22, 2021. The total allowed amount is $125.13 and 20% of
that is $25.03.
You received DME and related supplies on April 3, 2021. The total allowed amount is $167.69 and 20% of that is $33.54. You received DME and related supplies on April 22, 2021. The total allowed amount is $125.13 and 20% of that is $25.03. The total amount you owe is: $83.60. You have been asked to pay the total coinsurance amount of $83.60 for DME and related supplies. DME and related supplies fall within the DME and related supplies 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 DME and related supplies provided from March 22, 2021, to April 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill that includes transportation for non-medical needs, an allowance for healthy food purchases and/or electricity, water and/or phone bill payments (debit card), home assistance services (repairs).

You asked the Plan to pre-approve special supplemental benefits for the chronically ill that includes transportation for non-medical needs, an allowance for healthy food purchases and/or electricity, water and/or phone bill payments (debit card), home assistance services (repairs). The Plan denied your request. The Plan says the enrollee has none of the qualifying diagnoses, does not require intense care coordination, and has no high risk for hospitalizations or high risk for adverse health outcomes.

The Plan contract says that, in order to be eligible for special supplemental benefits for the chronically ill, you must have one or more comorbid and medically complex chronic conditions that are life-threatening or significantly limit your health or general functioning. In addition, you must have a high risk of hospitalization or other adverse health outcomes; and must require intensive care coordination. 

We looked at the file and Medicare rules. The file shows that your medical conditions are not eligible medical conditions for coverage under the Plan's benefit. Therefore, we decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill that includes transportation for non-medical needs, an allowance for healthy food purchases and/or electricity, water and/or phone bill payments (debit card), home assistance services (repairs).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a heavy-duty power scooter with bigger tires (K0807).
You asked the Plan to pre-approve the scooter. You say that this is medically necessary, as you have to go out in the gravel and dirt. The Plan denied your request. The Plan says this is not the most appropriate vehicle for use in the home.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The requested scooter has added capabilities that are meant for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Based on this information, we decided that Medicare rules for coverage of the scooter have not been met. Therefore, we decided that the Plan does not have to pre-approve a heavy-duty power scooter with bigger tires (K0807).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient psychiatric readmission beyond September 8, 2021.
You asked the Plan to pre-approve the inpatient psychiatric readmission. You say that the enrollee is still depressed, and their doctor has made adjustments to their medications. The Plan denied your request. The Plan says the mental health inpatient psychiatric services you are requesting do not meet the requirements for approval.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient psychiatric readmission. Our reviewer says that it does not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as the enrollee does not have any suicidal or homicidal thoughts, auditory or visual hallucinations or abnormal behaviors. Our physician reviewer found it does not appear that active treatment was taking place beyond the date in question. Our reviewer also found that it does not appear that the services for the dates in question are reasonably expected or medically necessary to improve the enrollee's condition or for the purpose of diagnosis. 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 inpatient psychiatric readmission have not been met. Therefore, we decided that the Plan does not have to pre-approve an inpatient psychiatric readmission beyond September 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the elective surgery provided on January 5, 2021.
You asked the Plan to reimburse you for the tubal reversal surgery. You say that you were told by your navigator that insurance was paying for your surgery. The Plan denied your request. The Plan says tubal reversal procedures are not covered by Medicare or the Plan.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at this the file and Medicare rules. This procedure is not covered by Medicare. Therefore, we decided that the Plan does not have to reimburse you for the elective surgery provided on January 5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a multiplex respiratory viral panel with 3-5 targets (87631)
provided on December 28, 2020.
You asked the Plan to pay for a multiplex respiratory viral panel. You say that this is supported in the records.
The Plan denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. Medicare rules say that multiplex respiratory viral panels of 3-5
pathogens are covered under limited circumstances. Specifically, the test must be ordered either in a healthcare
setting that is equipped to care for and routinely does care for critically ill patients, or it must be ordered by an
infectious disease specialist, unless an infectious disease specialist is not available. We looked at the file and Medicare rules. The records do not show that this testing was ordered in a healthcare
setting that is equipped to care for and routinely does care for critically ill patients or by an infectious disease
specialist. Based on this information, we decided that Medicare rules for coverage of a multiplex respiratory
viral panel have not been met. Therefore, we decided that the Plan does not have to pay for a multiplex
respiratory viral panel with 3-5 targets (87631) provided on December 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator.
You asked the Plan to pre-approve the concentrator. You say that this is medically necessary. The Plan denied your request. The Plan says this is being requested solely for the purpose of travel.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home and for travel. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an auricular nerve stimulator for the enrollee.
You asked the Plan to pre-approve the stimulator. You say that this is medically necessary. The Plan denied your request. The Plan says medical studies have not proven that this device is helpful for treatment of the health problem.
The Plan must follow Medicare rules. Medicare rules say that acupuncture for stimulation of auricular points is not a covered Medicare benefit. The requested device is not covered by Medicare or the plan. Based on this information, we decided that Medicare rules for coverage of the stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve an auricular nerve stimulator for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for extractions (D7210 x3), an upper partial denture (D5225), and a lower partial denture (D5226) provided from March 25, 2021, through April 29, 2021.
You asked the Plan to pay for extractions, an upper partial denture, and a lower partial denture. You say that you want the Plan to pay for these services. The Plan denied your request. The Plan says the services at issue 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 pay for extractions (D7210 x3), an upper partial denture (D5225), and a lower partial denture (D5226) provided from March 25, 2021, through April 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an ultrasound scan behind the abdominal
cavity (76770) provided on February 10, 2021.
You asked the Plan to waive the deductible for an ultrasound. You say that going to the appointment and
having this treatment was a waste of time. You also say that you should not have to pay for the doctor's
incompetence. The Plan denied your request. The Plan says the cost-share you are being charged is correct.
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 $203 deductible depending on your level of Medicaid. Your contract
with the Plan also says that based on the Plan benefits for outpatient radiology, you have a 20% coinsurance
after you pay the $203 deductible which applies to outpatient diagnostic tests and therapeutic services and
supplies. The service at issue is subject to the Plan deductible of $203. The record shows that at the time this claim was
processed, $97.89 of the $203 deductible had been met. The allowed amount of the claim is $105.11, resulting
in a deductible obligation of $105.11. The records also show that you received outpatient radiology services
and the billing provider in this case was the hospital. The Plan has followed Medicare rules by clearly
disclosing in the contract that there is a $203 deductible which applies to outpatient diagnostic tests and
therapeutic services and supplies. This cost sharing is a contractual obligation that had not been met at the time
an ultrasound was received on February 10, 2021. Therefore, we decided that the Plan does not have to waive
the deductible for an ultrasound scan behind the abdominal cavity (76770) provided on February 10, 2021.
Your complaint about the treatment you received, and the incompetence of the doctor 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.