Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.

You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied
your request. The Plan says the stay is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing
service needs. There are no identifiable skilled nursing service needs. The enrollee does not require skilled
nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of
service criteria for an inpatient basis in a SNF setting.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve SNF care.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound of the breast provided on December 11, 2020.
You asked the Plan to waive the copayment for an ultrasound of the breast. You say that this was a preventative mammogram and you should not be responsible for 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 a $50 copayment for diagnostic radiology services. The medical records show that you received a diagnostic ultrasound of the breast on December 11, 2020. Therefore, you are responsible to pay the $50 copayment.
You have been asked to pay a $50 copayment for an ultrasound of the breast. An ultrasound of the breast falls 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 an ultrasound of the breast provided on December 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bioimpedance spectroscopy (BIS), extracellular fluid
analysis for lymphedema assessment(s) (CPT code 93702), for the enrollee.
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan
denied your request. The Plan says a review of the current medical literature indicates that this service is
considered experimental and investigational as it is not identified as widely used and generally accepted for the
proposed use as reported in nationally recognized peer-reviewed medical literature published in the English
language.
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 service. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found a review of the current literature revealed lack of sufficient support for use of this assessment
for lymphedema. There is insufficient evidence to show benefit over current methods. Therefore, the
bioimpedance spectroscopy (BIS), extracellular fluid analysis for lymphedema assessment will be considered
not medically necessary 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 the service have not been met. Therefore, we decided that the Plan does not
have to pre-approve bioimpedance spectroscopy (BIS), extracellular fluid analysis for lymphedema
assessment(s) (CPT code 93702), for the enrollee.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay for the oral evaluation. We decided that the Plan does not have to pay for
the periapical x-ray.
You asked the Plan to pay for the oral evaluation. You say that you would have gone to the dentist much earlier
in the plan year if not for the coronavirus. You also say that an exception should be made. The Plan denied
your request. The Plan says that you are not eligible for an oral exam until August 2021. The Plan also says that
periapical x-ray is not a covered service.
We decided that the Plan has to pay for the oral evaluation.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. We find that the Plan denied the periodic oral evaluation due to frequency limit.
The Plan did not provided documentation to substantiate this claim. Documentation was requested but not
received. Therefore, we cannot determine if the frequency limit had been exceeded. Therefore, we decided that
the Plan has to pay for the oral evaluation.
We also decided that the Plan does not have to pay for the periapical x-ray.
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 periapical x-ray is not among those
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the periapical x-ray.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.

You asked the Plan to pre-approve incontinence supplies. You say that your father needs these supplies. The Plan denied your request. The Plan says this item is not a covered benefit.

The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. 

While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pre-approve a repeat colonoscopy for the enrollee.

You asked the Plan to pre-approve the colonoscopy. You say that you want to make sure there is no new growth or new polyps. The Plan denied your request. The Plan says that this request is for a six month interval.

The Plan must follow Medicare rules. The rules say that the medical records must support the medical reasonableness, necessity, and frequency of each diagnostic service supplied. 

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 colonoscopy. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the use of piecemeal technique on a large tubulovillous lesion as meets the enrollee's scenario raises the probability of incomplete removal. It is specialty-standard to resurvey on an accelerated recall schedule by optimally-prepped colonoscopy for a potentially incompletely-removed villous tumor. The proposed 6-month interval meets standard-of-care recommendations. 

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 colonoscopy have been met. Therefore, we decided that the Plan has to pre-approve a repeat colonoscopy for the enrollee.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi electric hospital bed (E0260).
You asked the Plan to pre-approve a hospital bed. You say that the medical records provided support the
necessity of the services in dispute. The Plan denied your request. The Plan says the available medical records
do not support necessity of this type of hospital bed as defined by Medicare criteria.
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered
medically necessary when the patient:
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or
2. Requires attachments which can only be attached to a hospital bed; AND
3. Requires frequent changes in body position and/or has an immediate need for a change in body position.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve a hospital bed. Our reviewer says that
the requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found there is documentation that the enrollee's condition requires positioning of the body in ways
not feasible in an ordinary bed including the need for elevating the head of the bed at least 30 degrees and
lower leg elevation but there is no documentation that the enrollee requires frequent changes in body position
or immediate changes in body position. There is no documentation that the enrollee's condition requires special
attachments that cannot be fixed and used on an ordinary bed and the records do not document the need for
frequent changes in body position or immediate changes in body position.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a hospital bed have not been met. Therefore, we decided that the Plan does not
have to pre-approve a semi electric hospital bed (E0260).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound study provided on June 11, 2021.

You asked the Plan to waive the copayment for an ultrasound study. You say that you disagree with how the claims were processed and feel that the Plan should pay 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 a $150 copayment for diagnostic procedures and tests, including ultrasounds. 

You have been asked to pay the allowed amount of $101.52, which is less than the $150 copayment for an ultrasound study. An ultrasound study falls 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 an ultrasound study provided on June 11, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tramadol 50mg tablets.
You asked the Plan to pre-approve the Tramadol tablets. You say that this is needed for chronic pain. The Plan
denied your request. The Plan says the oral drug is not covered by Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Tramadol 50mg tablets.
Benefits for the Tramadol tablets may be available under Medicare Part D. Contact the Plan that administers
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the urogynecological office visit to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the urogynecological office visit. You say that you do not want to see the recommended in-network doctor due to personal reasons. The Plan denied your request. The Plan says the provider is out-of-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 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 the urogynecological office visit to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visit to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the office visit. You say that you saw this provider years ago and he is familiar with your condition. You say you do not feel you will get adequate attention with another provider. The Plan denied your request. The Plan says the provider is out-of-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 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 the office visit to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.

You asked the Plan to pre-approve incontinence supplies. You say that you are on a fixed income and cannot afford these items. The Plan denied your request. The Plan says the requested items are not a covered benefit.

The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. 

While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visit to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the office visit. You say that you have called in-network providers with no luck. You say you are out of options. The Plan denied your request. The Plan says the provider is out-of-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 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 the office visit to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve gingival irrigations (D4921).

You asked the Plan to pre-approve the gingival irrigations. The Plan denied your request. The Plan says this service is not covered under the enrollee's benefit plan.

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 gingival irrigations (D4921).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for endodontic therapy provided on May 17, 2021.
You asked the Plan to pay for endodontic therapy. You say that you are appealing because you didn't get a copy of your insurance changing. The Plan denied your request. The Plan says the service is not a covered 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 pay for endodontic therapy provided on May 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve K3 microprocessor foot (L5973).
You asked the Plan to pre-approve the prosthetic foot. You say that please review all included documentation to see that the foot is medically necessary and overturn the denial. The Plan denied your request. The Plan says the request for a K3 microprocessor foot does not meet Medicare criteria as reasonable and 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 prosthetic foot. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the records show that the patient is active and meets K3 level. A powered ankle-foot was, however, not supported in the records. There was no clear explanation as to why the patient requires this feature for his basic functioning. He requires a new prosthesis, but the microprocessor component will be considered not medically necessary based on the documentation. 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 prosthetic foot have not been met. Therefore, we decided that the Plan does not have to pre-approve K3 microprocessor foot (L5973).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on November 28, 2020.

You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed in the Medicare rules section, are not covered.

The laboratory testing at issue in this appeal was requested solely for screening purposes. Medicare does not
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the
laboratory services provided on November 28, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the ground mileage (A0425) and non-emergency ambulance transport (A0428) provided on October 3, 2020.
You asked the Plan to pay for the ground mileage and non-emergency ambulance transport. You say that the ambulance services were unrelated to the enrollee's hospice condition. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the ground mileage (A0425) and non-emergency ambulance transport (A0428) provided on October 3, 2020.