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

We decided that the Plan does not have to pre-approve a large adjustable bed (A9270).
You asked the Plan to pre-approve a large adjustable bed. You say that the item is medically necessary. The
Plan denied your request. The Plan says neither Medicare or the Plan cover this item.
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. Based on this information, we decided that Medicare rules for
coverage of a large adjustable bed have not been met. Therefore, we decided that the Plan does not have to preapprove
a large adjustable bed (A9270).
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay an additional amount for the bifocal lens, anti-reflective coating and frames. We decided that the Plan does not have to fully pay for the bifocal lens, anti-reflective coating and frames.
You asked the Plan to fully pay for the bifocal lens, anti-reflective coating and frames. You say that the Plan is supposed to pay on the glasses. You say that the reason you got this Plan is to help you with these things. The Plan says that your maximum benefit has been exceeded.
We decided that the Plan has to pay an additional amount toward the bifocal lens, anti-reflective coating and frames.
The Plan says that $200 was paid toward the vision services provided on May 18, 2021. The records show the Plan only paid $145 toward the vision services. Therefore, we decided that the Plan has to pay an additional $55 toward the bifocal lens, anti-reflective coating and frames to meet the $200 yearly allowance.
We also decided that the Plan does not have to fully pay for the bifocal lens, anti-reflective coating and frames.
Your contract with the Plan says that there is a $200 allowance for supplemental eyewear every year and members are responsible for all costs over and above the allowance amount. This means that the Plan is only obligated to pay $200 toward the vision services. Therefore, we decided that the Plan does not have to fully pay for the bifocal lens, anti-reflective coating and frames.
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 all lower extremity prostheses, multiaxial rotation unit (MCP or equal) all lower extremity prostheses, shank foot system with vertical loading pylon).
You asked the Plan to pre-approve all lower extremity prostheses, multiaxial rotation unit (MCP or equal) all lower extremity prostheses, shank foot system with vertical loading pylon). You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested items are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that prostheses are only covered for certain 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 all lower extremity prostheses, multiaxial rotation unit (MCP or equal) all lower extremity prostheses, shank foot system with vertical loading pylon). Our reviewer says that the documentation does not support that the requested items are medically reasonable or necessary. Our physician reviewer found the enrollee's current hydraulic knee is not providing stability in stance phase and has buckled repeatedly, resulting in falls. There is no evidence in the documentation that the enrollee requires an entire prosthetic replacement or there is damage to the enrollee's current foot and ankle component. Therefore, the enrollee does not meet criteria for the requested items. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of all lower extremity prostheses, multiaxial rotation unit (MCP or equal) all lower extremity prostheses, shank foot system with vertical loading pylon) have not been met. Therefore, we decided that the Plan does not have to pre-approve all lower extremity prostheses, multiaxial rotation unit (MCP or equal) all lower extremity prostheses, shank foot system with vertical loading pylon).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the laser treatments provided from September 24, 2020, to October 6, 2020.
You asked the Plan to pay for the Class IV Laser and Soft Tissue treatment. You say that this procedure is covered and some claims have been paid. The Plan denied your request. The Plan says the records show you underwent laser treatment of nerve pain and this procedure is not covered under Medicare guidelines.
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. Medicare does not cover infrared therapy for peripheral neuropathy. Based on this information, we decided that Medicare rules for coverage of the infrared therapy have not been met for nerve pain. Therefore, we decided that the Plan does not have to pay for the laser treatments provided from September 24, 2020, to October 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on July 21, 2020.
You asked the Plan to pay for subsequent nursing facility care. The Plan denied your request. The Plan says that services rendered by non-participating providers require prior authorization as outlined in the enrollee's Evidence of Coverage.
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 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 subsequent nursing facility care provided on July 21, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (36415, 82248, 80053, 85025)
rendered by the OON provider on January 27, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of
network provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue.
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the
Plan does not have to pay for the laboratory services (36415, 82248, 80053, 85025) rendered by the OON
provider on January 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the peripheral nerve blocks provided on September 3, 2020.
You asked the Plan to pay for the services provided. You say that you have already paid for the service. The Plan denied your request. The Plan says the service was not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.
We looked at review, the file, and Medicare rules. There is insufficient evidence to support the use of peripheral nerve blocks in the treatment of peripheral neuropathies caused by other underlying systemic diseases or peripheral neuropathies causes such as degenerative or idiopathic reasons. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the peripheral nerve blocks provided on September 3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on April 15, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and paid The Plan denied your request. The Plan says prior authorization was not obtained for this lab work.
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 lab work provided on April 15, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code 22870), for the enrollee.
You asked the Plan to pre-approve the surgery. You say that the service is necessary. The Plan denied your request. The Plan says medical studies have not proven that the service(s) or procedure(s) is helpful for treatment of the enrollee's health problem.
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 surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show safety of the device. 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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code 22870), for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-emergency transportation by a wheelchair van (A0130) and mileage (S0209) provided on February 23, 2021.
You asked the Plan to pay for the transportation services. You say that you were taken to the hospital by ambulance. You say that you were discharged after 5 days. You say that you were taken back to the skilled nursing facility by a wheelchair van. You also say that this should be covered. The Plan denied your request. The Plan says Medicare will not pay for transport by wheelchair vans.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport services. The services you have asked the Plan to pay for are wheelchair van transport services. Therefore, we decided that the Plan does not have to pay for the non-emergency transportation by a wheelchair van (A0130) and mileage (S0209) provided on February 23, 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 service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee's medical problems are stable and there are no complex nursing or rehabilitation needs. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for a intensive, multi-disciplinary rehabilitation program.
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. Specifically, medically necessary services can be obtained at a lower level of care. This means admission into an IRF is not medically necessary or reasonable. 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 pay for sales tax (S9999) for a massage chair provided on February 24, 2021.
You asked the Plan to pay for sales tax. You say that you were told prior to purchase that the cost would be covered by the Plan. The Plan denied your request. The Plan says sales tax is included in the payment for durable medical equipment items and a separate payment is not covered under Medicare or the Plan.
The Plan must follow Medicare rules. Medicare rules say that Medicare does not reimburse separately for sales tax. We looked at the file and Medicare rules. The request is for separate reimbursement for sales tax. Based on this information, we decided that Medicare rules for coverage of sales tax have not been met. Therefore, we decided that the Plan does not have to pay for sales tax (S9999) for a massage chair provided on February 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not to waive the copayment for lab work and coinsurance for radiation therapy provided by a participating provider on September 14, 2020.
You asked the Plan to waive the copayment for lab work and coinsurance for radiation therapy. You say that you do not feel like you should be held responsible for this. The Plan denied your request. The Plan says the correct copayment and coinsurance has not been applied.
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 $6 copayment for outpatient diagnostic tests/lab and a 20% coinsurance for inpatient stay/radiation therapy.
You have been asked to pay a $6 copayment for lab work and a 20% coinsurance of the allowed amount radiation therapy. The total allowed amount is $380.95. The amount you are being asked to pay for radiation therapy is $76.19 ($380.95 x 20% = $76.19). The total amount you are being asked to pay is $82.19 ($76.19 + $6 = $82.19). Lab work falls within the outpatient diagnostic tests/lab benefit category. Radiation therapy falls within the inpatient stay/radiation therapy 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 lab work and coinsurance for radiation therapy provided by a participating provider on September 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on December 1, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was billed with an inappropriate diagnosis code.
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis code. We looked at the file and Medicare rules. The file shows that the services were billed with left, right, and unspecified laterality diagnosis codes, which is a mismatch. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on December 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for duplex scan of extremity veins including
responses to compression and other maneuvers (93971) provided March 30, 2021.
You asked the Plan to waive the copayment for the diagnostic services. You say that a previous claims for the
same services at the same location were appealed and overturned and you think this claim should have the
same resolution. The Plan denied your request. The Plan says this claim was processed with the correct
copayment applied per the Evidence of Coverage.
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 $25
copayment for Medicare covered ultrasound at a freestanding provider.
You have been asked to pay $25 copayment for the diagnostic service. The diagnostic service fall within the
Outpatient diagnostic tests and therapeutic services and 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 copayment for duplex scan of extremity veins including responses to compression and other
maneuvers (93971) provided March 30, 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 service is medically necessary. The Plan denied 
your request. The Plan says the service is not medically necessary. 
 
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 your medical problems are stable and you have no complex nursing or rehabilitation 
needs. While the documentation does support a need for physical and/or occupational therapy, there is no 
documented need for an intensive, multi-disciplinary rehabilitation program. 
 
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. Specifically, medically necessary services can be 
obtained at a lower level of care. This means admission into an IRF is not medically necessary or reasonable. 
Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) 
admission and services.
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 services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 documentation does not support the need for therapy program consisting of at least 3 
hours of therapy per day at least 5 days per week with frequent physician oversight and an interdisciplinary 
approach to rehabilitation care. IRF admission is not medically necessary. The enrollee's rehabilitation needs can be addressed in an alternate 
and less intense 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a cardioversion provided on March 17, 2021.
You asked the Plan to waive the copayment for a cardioversion. You say that you disagree with the charges and feel that the claims should be reprocessed. 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 a $350 copayment for outpatient surgery, including services provided at hospital outpatient facilities. You received a cardioversion at an outpatient hospital facility on March 17, 2021. Therefore, you are responsible to pay the $350 copayment. You have been asked to pay a $350 copayment for a cardioversion. A cardioversion falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 cardioversion provided on March 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal scaling in the presence of gingival
inflammation (D4346).
You asked the Plan to pre-approve the dental service. You say that you have not had a cleaning in a few years
and require these deep cleaning services. The Plan denied your request. The Plan says this service is not
covered by your dental benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve
periodontal scaling in the presence of gingival inflammation (D4346).