Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from January 18, 2021, to January 21, 2021.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you disagree with the charges and the service you receive from the Plan with your kidney disease care. 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 $250 copayment for days 1-7 for inpatient hospital care. You had an inpatient hospital stay provided from January 18, 2021, to January 21, 2021. Therefore, you are responsible to pay a $250 copayment for days 1-3 (January 18, 2021, to January 20, 2021).
The total amount you owe is: $250 (copayment) x 3 (inpatient days) = $750. You have been asked to pay the total copayment amount of $750 for inpatient hospital care. Inpatient hospital care falls within the inpatient hospital care 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 inpatient hospital care provided from January 18, 2021, to January 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve extracorporeal shock wave therapy (ESWT).
You asked the Plan to pre-approve extracorporeal shock wave therapy. You say that you feel that the
extracorporeal shock wave therapy is medically necessary based on the enrollee's plantar fascial fibromatosis.
The Plan denied your request. The Plan says this service is not covered under Medicare.
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 extracorporeal shock wave therapy have not been met. Therefore, we decided that the Plan does
not have to pre-approve extracorporeal shock wave therapy (ESWT).
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve disposable filters for a positive airway pressure (PAP) device
(A7038) to be provided at a frequency of 6 filters every 3 months.
You asked the Plan to pre-approve PAP device filters. You say that you would have to pay a shipping charge
each month for a smaller order, so you want to get 6 filters every 3 months with the rest of your quarterly
orders. The Plan denied your request. The Plan says that the denial of authorization for these supplies is correct,
because Medicare guidelines do not allow for more than 2 filters per month.
The Plan must follow Medicare rules. Medicare rules say that disposable filters for a PAP device are covered
up to 2 per 1 month.
We looked at the file and Medicare rules. Your request to order filters at a quantity of 6 filters per 3 months is
within the Medicare frequency limit of 2 filters per 1 month. These filters can be supplied in a 3-month interval
but still be billed to the Plan in 1-month intervals to reflect Medicare's 1-month periods for coverage of
disposable filters. The Plan has not provided any other rationale or evidence to support denial of the requested
disposable filters. Based on this information, we decided that Medicare rules for coverage of PAP device filters
have been met. Therefore, we decided that the Plan has to pre-approve disposable filters for a positive airway
pressure (PAP) device (A7038) to be provided at a frequency of 6 filters every 3 months.
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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a laparoscopy (43284).

You asked the Plan to pre-approve the laparoscopy. You say that this procedure is medically necessary and warrants coverage in this case. The Plan denied your request. The Plan says this service is not covered.

The Plan must follow Medicare rules. Medicare rules say that laparoscopy code 43284 is not covered by Medicare. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laparoscopy have not been met. Therefore, we decided that the Plan does not have to pre-approve a laparoscopy (43284).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve fluorouracil cream.
You asked the Plan to pre-approve fluorouracil cream. You say that the patient requires field treatment of an
area too large for other topical medications. The Plan denied your request. The Plan says this medication falls
under Part D coverage and the member does not have Part D pharmacy (drug) benefits.
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 fluorouracil cream
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power scooter.
You asked the Plan to pre-approve the scooter. You say that this is medically necessary. The Plan denied your
request. The Plan says a group 2 power wheelchair is the most appropriate option.
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 scooter. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found based on the medical records provided, the group 2 power wheelchair the most appropriate item for the
enrollee.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the scooter have not been met. Therefore, we decided that the Plan does not
have to pre-approve a power scooter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the crowns and the fixed bridge.
You asked the Plan to pre-approve the crowns and fixed bridge. You say that the crown is loose, and the dentist
said this is the only way to fix it. The Plan denied your request. The Plan says the services are not medically
necessary.
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 crowns
and fixed bridge 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 crowns and fixed bridge. Our
reviewer says that the criteria for coverage has not been met. Our physician reviewer found that tooth #'s 23-26
do not show significant coronal breakdown due to caries or fracture to warrant crown restorations. Our
reviewer says that the patient appears to have adequate masticatory function with the present natural teeth and
fixed bridges to replace missing posterior teeth are not a covered expense.
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 crowns and fixed bridge have not been met. Therefore, we decided that the
Plan does not have to pre-approve the crowns and the fixed bridge
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a ramp.
You asked the Plan to pre-approve the ramp. You say that this is medically necessary. The Plan denied your
request. The Plan says there is no documentation showing proof of ownership of the home.
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 ramp.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit to be rendered by the out-of-network
(OON) provider.
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's
denial. The Plan denied your request. The Plan says there are in-network providers available to render the
requested service.
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 requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the service at issue in this appeal. We found no exception that would require the
Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve an office
visit to be rendered by the out-of-network (OON) provider
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive one of the copayments for a physician visit provided on June 1, 2021.
You asked the Plan to waive one of the copayments for a physician visit. You say that you should have only
been charged a $30 copayment. The Plan denied your request. The Plan says that you have been charged the
correct cost sharing amount.
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 enrollees must pay a $30 copayment for each out of network primary care
physician office visit.
The Plan says you must pay two $30 copayments for one physician visit. Although annual wellness was
addressed in your visit, you only had one primary care physician visit. Based on the Plan contract, you cannot
be asked to pay more than one $30 copayment for a physician visit. Therefore, we decided that the Plan has to
waive one of the copayments for a physician visit provided on June 1, 2021.
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: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the breast with computer-
aided detection (CAD).
You asked the Plan to pre-approve the imaging. You say that this is medically necessary. The Plan denied your
request. The Plan says that screening imaging is not recommended for the left reconstruction post mastectomy.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 the imaging. Our reviewer says that the
requested imaging is medically reasonable and necessary. Our physician reviewer found MRI of the breasts
would be reasonable and necessary for in light of the lack of radiation therapy, and due to the history of four
positive nodes at surgery. Your body habitus is large, and the use of mammography and ultrasound would be
limited. Based upon these factors, the requested MRI is 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 the imaging have been met. Therefore, we decided that the Plan has to pre-
approve magnetic resonance imaging (MRI) of the breast with computer-aided detection (CAD).
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional levels for paravertebral facet joint
radiofrequency ablation.
You asked the Plan to pre-approve the additional levels. You say that ablation is a regular tool to help with
control and mobility. The Plan denied your request. The Plan says one to two levels, either unilateral or
bilateral, are allowed per session per spine region.
The Plan must follow Medicare rules. Medicare rules say that one to two levels, either unilateral or bilateral,
are allowed per session per spine region.
There is no documentation of any circumstances that would necessitate additional levels being treated above
the usual Medicare benefit, as there is documentation that the request for additional levels was a mistake on the
part of the provider. The provider requested a withdrawal of the additional codes. Based on this information,
we decided that Medicare rules for coverage of the additional levels have not been met. Therefore, we decided
that the Plan does not have to pre-approve additional levels for paravertebral facet joint radiofrequency
ablation
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower
denture (D5120).
You asked the Plan to pre-approve the dental items. You say that you need a denture. You say that you do not
have have teeth. You also say that you are having a hard time eating. The Plan denied your request. The Plan
says dentures are covered once every 5 plan years. The Plan also says that the frequency limit has been
reached.
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.
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for
coverage of the dental items have not been met. Specifically, the frequency limit has been reached. The record
shows that the Plan paid for dentures that you received on April 18, 2018. Therefore, we decided that the Plan
does not have to pre-approve a complete upper denture (D5110) and a complete lower denture (D5120).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the Up Walker to be provided by a non-Medicare provider.
You asked the Plan to pay for the Up Walker. You say that the request was denied because you have this
product in your possession. The Plan denied your request. The Plan says on March 23, 2021, you spoke with
your physician about your need for a walker due to your limited walking ability because of your severe
osteoarthritis. The Plan states a request for coverage of a Heavy-Duty Wheeled Walker, CPT code Current
Procedural Terminology (CPT) code E0149) was entered and coverage for this walker was authorized, but you
did not accept the heavy-duty walker supplied by the Plan's network vendor. The Plan states you were
subsequently seen by your primary care physician on May 25, 2021, and you noted that you were trying to
obtain an "upright walker." The Plan states you said you did not want to have a walker that causes you to
"stoop over." The Plan states on June 9, 2021, a new request was entered for an Up Walker from another DME vendor in the Plan's network and coverage for this walker was denied and that denial is the subject of this appeal.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
Based on this information, we decided that Medicare rules for coverage of the Up Walker have not been met.
The Plan states they contacted the other provider regarding this request for an Up Walker since they do offer
this walker. The vendor noted that the requested Up Walker has no specific Healthcare Common procedure
Coding System (HCPCS) and that the Manufacturer has never requested a code for the Up Walker. Since there
is no established Medicare code this this item, there are no established billing or reimbursement codes.
Therefore, they state that though they offer this item, it is retail only, they do not bill Medicare for this item as it is not considered a covered benefit. Since the manufacturer of the Up Walker is not enrolled in Medicare and has never requested a specific HCPCS for the device, the device is not covered per Medicare rules. You can purchase an Up Walker as a retail item through them but the cost of an Up Walker cannot be covered by your health plan or Medicare as Medicare rules state that claims submitted by suppliers that are not enrolled in Medicare cannot be paid (the "supplier" of the device is the manufacturer of
the walker in this case). Therefore, we decided that the Plan does not have to pay for the Up Walker to be
provided by a non-Medicare provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve tertiary care with an out of network (OON) provider.
You asked the Plan to pre-approve the OON tertiary care. You say that you do not feel confident seeing another doctor. You say that the previous treatment with doctors within the network for your congestive heart failure was not sufficient. You say that the in-network doctors did not do anything for you. You say that you are currently using a pacemaker for your heart. The Plan denied your request. The Plan says they have multiple in network cardiology specialists and tertiary level care centers available that can provide the enrollee with a second opinion and treatment for her condition.
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care.
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 OON tertiary care. Our reviewer says that the criteria for coverage of OON care have not been met. Our physician reviewer found the enrollee likely has multi-factorial causes of her symptoms of dyspnea and edema likely relating to combined cardiopulmonary disease. Although she has had an extensive and thorough evaluation at her local hospital, she remains symptomatic and the etiology of her continued symptoms is not specifically delineated, though it is likely a mixed cardiopulmonary picture. In this instance, a referral to a tertiary cardiac/pulmonary center is appropriate for a second opinion as this has not yet been undertaken. Based on the records provided there does not appear to be anything specifically unique to her condition that the OON clinic has specific expertise to evaluate and treat compared to the other excellent and highly rated in network regional tertiary providers of cardiopulmonary and congestive heart failure care. The Plan's referenced in network tertiary care facilities are all highly ranked Florida hospitals with excellent tertiary cardiovascular programs with specialty tertiary cardio-pulmonary services and providers available for the evaluation and management of her condition. As such, an in-network referral to one of those tertiary centers and providers is a reasonable and appropriate next step in her care. 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 OON tertiary care have not been met. Therefore, we decided that the Plan does not have to pre-approve tertiary care with an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve interprofessional telephone/internet/electronic health record consultation (99452).
You asked the Plan to pre-approve interprofessional consultation. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says there is no documentation that supports a diagnosis for Dysautonomia or a requested order from a medical provider stating member needs to see a specialist out of state.
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 interprofessional consultation. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found after review of her medical notes, there was no confirmed diagnosis of Dysautonomia by the neurologists she saw at the Clinic. The review indicates that the items/services at issue in this case are not medically reasonable or necessary for the enrollee 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 interprofessional consultation have not been met. Therefore, we decided that the Plan does not have to pre-approve interprofessional telephone/internet/electronic health record consultation (99452).