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

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets LTACH admission 
criteria. You say that the enrollee is stable and suitable for transfer to an LTACH. You say that the enrollee 
cannot be adequately care for in her current condition at a skilled nursing facility. You say that the enrollee 
requires prolonged hospitalization and close physician monitoring. The Plan denied your request. The Plan says 
the guidelines for coverage of LTACH care have not been met. The Plan says that the enrollee's care can be 
provided in the current inpatient hospital. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation provided indicating medical necessity for admission to a 
LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not 
require services at the LTACH that are not available at the acute care hospital where he is currently receiving 
care. There are no services available at the LTACH that the enrollee requires that are not available at the health
care setting being offered by the health plan. The requested LTACH services are not medically necessary, 
reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and 
effectively only on an inpatient basis. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the residual tooth roots removal and consultation provided on 
May 7, 2021. 
 
You asked the Plan to pay for the residual tooth roots removal and consultation. You say that you paid out of 
pocket and want to be reimbursed. 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 pay for the residual tooth roots removal and consultation 
provided on May 7, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient services provided from April 15, 2020, to April
20, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed diagnosis
code is not supported.

The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or
provider must corroborate the documentation in the beneficiary's medical documentation and confirm that
Medicare coverage criteria have been met.

We looked at the file and Medicare rules. The submitted documentation does not contain medical records from
the non-contract provider for the dates of service in question. Without records, it cannot be determined that
Medicare coverage criteria have been met. 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 pay for the
inpatient services provided from April 15, 2020, to April 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the wheelchair lift purchased on March 18, 2021 from a provider not certified by Medicare.
You asked the Plan to reimburse you for the wheelchair lift. You say that you cannot use stairs and the lift is needed to get to your second-floor residence. The Plan denied your request. The Plan says the supplier is not included in Medicare's Supplier Directory as a certified provider.
Medicare rules say that for equipment to be covered it must be purchased from a Medicare certified supplier. Medicare will only cover your durable medical equipment (DME) if your DME supplier is enrolled in Medicare. Suppliers have to meet strict standards to enroll and stay enrolled in Medicare. This supplier is not a Medicare certified supplier. Therefore, we decided that the Plan does not have to reimburse you for the wheelchair lift purchased on March 18, 2021 from a provider not certified by Medicare.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for progressive lenses (V2781) provided on June 9, 2021.
You asked the Plan to pay for progressive lenses. You say that you are unclear as to which service/products are not covered. You also say that you did not receive an itemized bill or statement, so you are unable to tell which service/products are being denied. The Plan denied your request. The Plan says you exceeded the $100 vision allowance benefit.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan contract says you have a $100 allowance once per year to use towards eyewear. We looked at the file and the Plan's rules. The records show you exhausted your $100 maximum allowed benefit. The records also show you purchased polycarbonate lenses at an allowed amount of $19.38, lens tint at an allowed amount of $32.82, anti-reflective coating at an allowed amount of $47.80 and progressive lenses at $279, for a total amount of $379 ($19.38 + $32.82 + $47.80 + $279 = $379). The Plan applied your $100 allowance which left you with a balance of $279 ($379 - $100 = $279). Based on this information, we decided that the Plan's rules for coverage of progressive lenses have not been met. Therefore, we decided that the Plan does not have to pay for progressive lenses (V2781) provided on June 9, 2021.
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 a power scooter. You say that you have been using a pushcart and need the power scooter to help with everyday activities. The Plan denied your request. The Plan says you do not meet criteria for the requested device.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.
The file shows that your condition can be improved by a walker, cane or manual wheelchair. In addition, the documentation shows that you are requesting this item to be used outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a power scooter.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services you received on May
16, 2021.

You asked the Plan to waive the copayment for the ambulance services. You say that you were told that if you
were admitted to the hospital, your ambulance copayment would be waived. The Plan denied your request. The
Plan says you were charged this copayment correctly.

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 $240
copayment for ambulance services.

You have been asked to pay a $240 copayment for the ambulance services. There is no provision in your
contract for a waiver of this copayment even if you are admitted to the hospital. 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 ambulance services you received on May 16, 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 enrollee will be best served in an IRF in order to 
return home safely. The Plan denied your request. The Plan says the criteria for admission to an IRF are not 
met. The enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of care. 
 
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 that the complexity of the enrollee's nursing, medical and rehabilitation needs 
does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does require physical and occupational therapy, but these can be provided in an alternate, low intensity 
level of care. Documentation does not support the need for a therapy program consisting of at least three hours 
of therapy per day at least five days per week with frequent physician oversight and an interdisciplinary 
approach to rehabilitation care. While the enrollee may benefit from physical and occupational therapy, their 
rehab needs can be safely met in an alternate 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 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Amitiza.
You asked the Plan to pre-approve this drug. You say that this is the only medication that has been effective. The Plan denied your request. The Plan says that this is not covered under Part B.
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 Amitiza.
Benefits for this drug 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sensor, transmitter, and receiver for a continuous
glucose monitor (CGM).
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the services are not covered. The Plan must follow Medicare rules. Medicare rules say that a sensor, transmitter, and receiver described by
codes A9278, A9277, and A9276 are for a non-covered continuous glucose monitor.
We looked at the file and Medicare rules. The requested services are a sensor, transmitter, and receiver
described by codes A9278, A9277, and A9276. These items are not covered by Medicare. Based on this
information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we
decided that the Plan does not have to pre-approve a sensor, transmitter, and receiver for a continuous glucose
monitor (CGM).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiological supervision and interpretation of percutaneous transhepatic portography coded 75887 and the radiological supervision and interpretation of angiography coded 75726 and 75774 provided on January 27, 2021.
You asked the Plan to pay for the radiological supervision and interpretation of percutaneous transhepatic portography and the radiological supervision and interpretation of angiography. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. e find that CPT codes 75887, 75726, and 75774 are not supported in the medical record. Specifically, the documentation shows that codes are documented in the operative notes; however, these procedures are considered inclusive to code 37243, a vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; for tumors, organ ischemia, or infarction; therefore, the codes cannot be verified. Based on this information, we decided that Medicare rules for coverage of the radiological supervision and interpretation of percutaneous transhepatic portography and the radiological supervision and interpretation of angiography have not been met. Therefore, we decided that the Plan does not have to pay for the radiological supervision and interpretation of percutaneous transhepatic portography coded 75887 and the radiological supervision and interpretation of angiography coded 75726 and 75774 provided on January 27, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Enbrel for the enrollee.

You asked the Plan to pre-approve Enbrel. You say that this is medically necessary. The Plan denied your
request. The Plan says that this is not covered under 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 Enbrel for the enrollee.

Benefits for Enbrel 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 2 very heavy-duty power operated vehicle
(K0808).

You asked the Plan to pre-approve a power operated vehicle. You say that the requested item is a necessity for
your care. The Plan denied your request. The Plan says the requested item is not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that if a Group 2 POV is provided it 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 a power operated vehicle have not been met. Specifically, the request is for a Group 2 POV.
Therefore, we decided that the Plan does not have to pre-approve a Group 2 very heavy-duty power operated
vehicle (K0808).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee.
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says this is considered investigational and is not recommended for patients with severe cardiac or pulmonary compromise.
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 procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this procedure is experimental for low back pain. More research is needed. 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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the medical eye exam you received on May 20, 2021.

You asked the Plan to waive the copayment for the medical eye exam. You say that you have not been billed in the past for an office visit when you get an injection. The Plan denied your request. The Plan says you were charged this copayment correctly.

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 $15 copayment for medical eye exams. 

You have been asked to pay a $15 copayment for the medical eye exam. The records show that you were evaluated for exudative age-related macular degeneration, pseudophakia, and dry eye syndrome on this date of service. This evaluation is separate from any injection you may receive, which is why the copayment applied. 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 the medical eye exam you received on May 20, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment for the telehealth visit you had with a provider at an
outpatient hospital-based clinic on September 25, 2020.

You asked the Plan to waive the copayment for the outpatient hospital clinic telehealth visit. You say that you
received services with your primary care doctor, so you believe the copayment should be $5. The Plan denied
your request. The Plan says that you were charged this copayment correctly. The Plan says that the provider
you met with on this date is a hospital-based provider, so the hospital copayment applies. You received a notice
from this hospital advising you that this provider bills as an outpatient hospital and you signed the letter
acknowledging that you understood this on September 22, 2020. Finally, the Plan says that because the allowed
amount for this visit ($26.65) is less than your copayment obligation, you are responsible for the full allowed
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). In this case, we agree with the Plan that you received these services
from a hospital-based provider. However, the Plan has failed to state what specific cost sharing section of your
Evidence of Coverage (EOC) they applied to this service. Your contract with the Plan does not say in clear and
accurate terms how much you should expect to pay for telehealth services you receive with a provider at an
outpatient hospital-based clinic. The only cost sharing amounts listed for outpatient hospital services include
cost sharing that applies to the following: diagnostic procedures and tests, advanced imaging services, nuclear
medicine, basic radiological services, mammography, radiation, lab services, surgery, mental health, and
emergency services. There is no section in the outpatient hospital services portion of the EOC that applies to
physician or clinic services. In addition, the Plan's case file fails to identify which specific cost sharing section
of the EOC they have applied. Because of this information, we find that the Plan's contract does not clearly
disclose what the cost sharing would be for this service. This means that the Plan did not follow Medicare rules
for disclosure of cost sharing information. Therefore, we decided that the Plan has to waive the copayment for
the telehealth visit you had with a provider at an outpatient hospital-based clinic on September 25, 2020.

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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (99380) provided on March 29, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled service.
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "B" under the Physician Fee Schedule indicates that payment for covered services are always bundled into payment for other services not specified. We looked at the file and Medicare rules. Code 99380 is assigned a status indicator of "B" under the Physician Fee Schedule, which means that this is a bundled service. Payment for this service is bundled into payment for other services. No separate payment can be made for this service. 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 pay for the services (99380) provided on March 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the durable medical equipment (DME) supplies, provided on April 30, 2021, and May 13, 2021.
You asked the Plan to pay for the DME supplies. You say that the items should be covered. The Plan denied your request. The Plan says you have already utilized your maximum allowed wallet benefit.
The Plan must follow Medicare rules. Medicare rules say that MA plans may choose to offer some benefits to enrollees in addition to the covered Medicare Part A and Part B (and Part D, as applicable) benefits. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of durable medical equipment supplies have not been met. Specifically, records indicate you have exhausted your plan benefits. Therefore, we decided that the Plan does not have to pay for the durable medical equipment supplies provided on April 30, 2021 and May 13, 2021. Therefore, we decided that the Plan does not have to pay for the durable medical equipment (DME) supplies, provided on April 30, 2021, and May 13, 2021.