Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the online digital evaluation and management service provided on January 30, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the online digital evaluation and management service. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the online digital evaluation and management service provided on January 30, 2021 by an out-of-network (OON) provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor.

You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. 

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, use insulin with at least three daily injections, or require frequent
self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on March 27, 2020, by an OON
provider.

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 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 requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the office visit provided on March 27, 2020, by an
OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on April 8, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 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 services provided by an out-of-network provider on April 8, 2021.
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 a power seat elevation feature. You say that the item is medically necessary. The Plan denied your request. The Plan says this item is not primarily medical in nature.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve for the surgical procedure for isolation of tooth with rubber dam (D3910), canal preparation and fitting of preformed dowel or post (D9350) and drugs or medicaments (D9630).
You asked the Plan to pre-approve for the surgical procedure for isolation of tooth with rubber dam (D3910), canal preparation and fitting of preformed dowel or post (D9350) and drugs or medicaments (D9630). 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 for the surgical procedure for isolation of tooth with rubber dam (D3910), canal preparation and fitting of preformed dowel or post (D9350) and drugs or medicaments (D9630).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric treatment.
You asked the Plan to pre-approve inpatient psychiatric treatment. 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 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 inpatient psychiatric treatment. Our
reviewer says that the services are not medically necessary.
Our physician reviewer found based upon review of the records provided, you do not meet the criteria for
treatment in an acute inpatient mental health treatment beyond the date in question of September 27, 2021
forward and could have been treated in a lesser restrictive setting. You were not showing any suicidal or
homicidal ideation, auditory or visual hallucinations, delusions and was not showing any behaviors or
aggression. You were being cooperative and compliant while not showing any acute threats to safety.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of inpatient psychiatric treatment have not been met. Therefore, we decided that
the Plan does not have to pre-approve inpatient psychiatric treatment.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete mandibular denture (D5120).
You asked the Plan to pre-approve the complete mandibular denture. You say that your lower denture was accidentally thrown away and you are unable to eat. The Plan denied your request. The Plan says this service is allowed one time every 60 months. The Plan also says that you have had this service less than 60 months ago.
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, dentures are limited to one set every 5 years. The record shows that you received a complete mandibular denture (D5120) on October 27, 2020 and your mandibular denture benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve a complete mandibular denture (D5120).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network laboratory.

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 available from network providers.

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 items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
a referral to an out-of-network laboratory.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on
February 9, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are
available in-network.

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 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 services provided by an out-of-network provider on February
9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two guided tissue regenerations (D4266 x2) and two repairs of maxillofacial soft and/or hard tissue defects (D7955 x2).

You asked the Plan to pre-approve the guided tissue regenerations and repairs of maxillofacial soft and/or hard tissue defects. You say that the work you need done is not cosmetic. The Plan denied your request. The Plan says these 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 two guided tissue regenerations (D4266 x2) and two repairs of maxillofacial soft and/or hard tissue defects (D7955 x2).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the ten skilled nursing visits (G0300 x10) and four PT
visits (G0151 x4).

You asked the Plan to pre-approve the skilled nursing visits and PT visits. You say that the enrollee needs all of
these visits. The Plan denied your request. The Plan says this request is not medically necessary.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.

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 skilled nursing visits and PT visits.
Our reviewer says that the skilled nursing visits and PT visits are not medically reasonable and necessary for
the enrollee. Our physician reviewer found there is no documentation provided showing that skilled nursing
services or skilled therapy services are required to effectively provide treatment, care, and/or services in order
to improve the enrollee's condition, or to establish/perform a maintenance program to maintain the enrollee's
condition and/or prevent deterioration for the unapproved visits. Our reviewer also found that the provided
records do not document why the two additional approved skilled nursing visits or the two additional approved
PT visits are inadequate to treat the enrollee's condition.

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 skilled nursing visits and PT visits have not been met. Therefore, we
decided that the Plan does not have to pre-approve the ten skilled nursing visits (G0300 x10) and four PT visits
(G0151 x4).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.

You asked the Plan to pre-approve a shower chair. You say that you are wheelchair-bound and have pain in both knees. The Plan denied your request. The Plan says the item is not covered.

The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. 

While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E1007,
E2300, E2311, E2377).
You asked the Plan to pre-approve the services. You say that a previous wheelchair was covered with all of the
features that you needed. The Plan denied your request. The Plan says this is 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 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 services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found E1007 is not medically necessary, as the documentation does not reveal a high risk of a pressure ulcer,
inability to perform a functional weight shift, use of intermittent catheterization for bladder management, or the
need to use the requested device to managed increase tone or spasticity. The Medicare rules say that the power
seat elevation feature (E2300) is not covered because as it is not primarily medical in nature. The E2377
Expandable Controller and E2311 are not medically necessary, as the documentation does not reveal that you
require other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin
control, head control, etc.) or non-proportional input devices (e.g., sip and puff, head array, etc.). You do not
need to operate 3 or more powered seating actuators through the drive control, a separate display (i.e., for
alternate control devices), other electronic devices (e.g., control of an augmentative speech device or computer
through the chair's drive control), or an attendant control. Your strength in the upper extremities supports that
you can control any power options through their own individual switches.
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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve additional power wheelchair accessories (E1007, E2300, E2311, E2377).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transcutaneous electrical nerve stimulators (TENS) unit.
You asked the Plan to pre-approve a TENS unit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says you do not meet criteria for the requested item.
The Plan must follow Medicare rules. Medicare rules say that a TENS unit is covered when the enrollee is enrolled in an approved clinical study. We looked at the file and Medicare rules. Review of the file does not support that you are enrolled in a clinical study. Based on this information, we decided that Medicare rules for coverage of a TENS unit have not been met. Therefore, we decided that the Plan does not have to pre-approve a transcutaneous electrical nerve stimulators (TENS) unit.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for a colonoscopy provided on April 30, 2021.

You asked the Plan to waive the deductible for a colonoscopy. You say that you feel that this was a preventative colonoscopy screening and the Plan should fully cover 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. Your contract with the Plan says that there is a $750 deductible which applies to outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. The medical records show that you had a polyp removed during a colonoscopy on April 30, 2021. Therefore, the colonoscopy is considered diagnostic, not preventative, and you are responsible to pay your share of the cost-sharing charges.

The record shows that you had only paid $136.46 toward the $750 deductible prior to receiving the services. Therefore, you are responsible to pay the total allowed amount of $484.60. 

The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible which applies to outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. This cost sharing is a contractual obligation that had not been met at the time a colonoscopy was received on April 30, 2021. Therefore, we decided that the Plan does not have to waive the deductible for a colonoscopy provided on April 30, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional transportation.

You asked the Plan to pre-approve the additional transportation. You say that you are completely disabled due
to your stroke, have no use of your right side, and are unable to drive yourself to the pharmacy or gym. You
also say that you need more specialist rides. The Plan denied your request. The Plan says the plan will provider
thirty (30) one-way rides with a limit of 50 miles per one-way trip. The Plan also says that additional coverage
outside of your covered benefits cannot be approved.

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 a maximum of up to 30 one-way trips per year.

We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that you are asking for more than the 30 covered trips of routine transportation. The record shows that as of
September 7, 2021, you have 28 of 30 trips remaining. Therefore, we decided that the Plan does not have to
pre-approve additional transportation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the oxygen concentrator (E1390).
You asked the Plan to pre-approve the oxygen concentrator. You say that you need the oxygen equipment to have relief from the near unendurable pain of cluster headaches. The Plan denied your request. The Plan says the Health Plan and Medicare does not cover oxygen concentrators and portable gaseous 02, for treatment of cluster headaches.
The Plan must follow Medicare rules. Medicare rules say that claims for stationary oxygen equipment other than E0424 and all portable oxygen equipment used for cluster headaches will be denied as not reasonable and necessary. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the oxygen concentrator have not been met. Therefore, we decided that the Plan does not have to pre-approve the oxygen concentrator (E1390).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the foot x-ray provided on September 2, 2020, by an OON
provider.
You asked the Plan to pay for these services. You say that you did not know that prior authorization was
needed. 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 requested provider in this case is not a network provider with the Plan. There is no referring network
provider. The Plan had network providers available who could have provided the items/services at issue in this
appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the
Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the foot x-ray
provided on September 2, 2020, by an OON provider.