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

We decided that the Plan does not have to pre-approve electronic connection between wheelchair controller and two or more power seating system motors, including all related electronics, indicator feature, mechanical function selection switch, and fixed mounting hardware (CPT code E2311), expandable controller, including all related electronics and mounting hardware, upgrade provided at initial issue (CPT code E2377), and harness for upgrade to expandable controller, including all fasteners, connectors and mounting hardware, each (CPT code E2313), for the enrollee.

You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your request. The Plan says the DME is not necessary.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. E2377 Expandable Controller, E2313 Expandable Controller Harness and E2311 Electro Connect Btw 2 Sys Electro Connect Btw 2 Sys are requested to control power tilt and power elevating leg rests through the joystick. The notes state that these are needed when 2 or more actuators are being used. The electrical connection between the wheelchair controller and two or more motors (E2311), expandable controller (E2377) and harness (E2313) cannot be covered. Although there are three approved power options on this wheelchair (tilt, recline and elevating leg rests), there is not a medical need to control these power options through the joystick. Documentation shows that Member has 3/5 bilateral upper limb strength and is independent with feeding and grooming. Upper limb strength and function are adequate for the member to be able to control the power options using their own switches which are included in the allowance of these power options. Therefore, we decided that the Plan does not have to pre-approve CPT code(s): E2311, E2377, and E2313, for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a medical service (99053) provided on April 22, 2021.

You asked the Plan to pay for medical service. You say that no coding change is required and denying
coverage is a violation of the prudent layperson standard. The Plan denied your request. The Plan says the
denial of payment for this service is correct, because code 99053 is always bundled for payment and is not
separately payable.

The Plan must follow Medicare rules. Medicare rules say that code 99053 is always bundled for payment and if
this service is covered, payment for it is subsumed by the payment for the services to which it is incident.

We looked at the file and Medicare rules. This code is always bundled for payment and is not separately
payable. Based on this information, we decided that Medicare rules for coverage of medical service have not
been met. Therefore, we decided that the Plan does not have to pay for a medical service (99053) provided on
April 22, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve nine (9) Lymphedema therapy sessions.

You asked the Plan to pre-approve nine (9) Lymphedema therapy sessions. You say that after surgery for a shoulder injury, you became unable to grip with your left arm and during physical therapy, right after surgery is when this began. You say that during work conditioning, it was suspected to be lymphedema. The Plan denied your request. The Plan says lymphedema therapy sessions are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that services must be under accepted standards of medical practice and considered to be specific and effective treatment for the patient's condition.

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 Lymphedema therapy sessions. Our reviewer says that Lymphedema therapy sessions are not medically necessary. Our physician reviewer found that the review has determined that you report a history of intermittent swelling in the arm (though none noted at the time you were seen) as you did have previous rotator cuff surgery in your left arm, and this could have damaged lymphatic channels in the arm leading to lymphedema. You have been approved coverage for six (6) visits for lymphedema therapy to have a trained lymphedema therapist examine you and assess if you do have lymphedema. If it is determined that you have lymphedema, a comprehensive lymphedema treatment program can be initiated. The review has determined that you do not meet the coverage criteria per the Medicare Coverage Article A52959 guidance. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of nine (9) Lymphedema therapy sessions have not been met. Therefore, we decided that the Plan does not have to pre-approve nine (9) Lymphedema therapy sessions.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral exam (D0150), complete series of intraoral x-rays (D0210), and resin-based composites (D2332, D2391, D2392 x3, and D2393) provided from October 12, 2020, to December 22, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the comprehensive oral exam, complete series of intraoral x-rays, and resin-based composites. You say that you were told that this provider accepted your insurance. The Plan denied your request. The Plan says the treating provider does not participate with your plan. The Plan also says that your plan does not allow payment for services done by non-participating dentists.
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 covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the comprehensive oral exam (D0150), complete series of intraoral x-rays (D0210), and resin-based composites (D2332, D2391, D2392 x3, and D2393) provided from October 12, 2020, to December 22, 2020 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomography (CT) scan services.
You asked the Plan to pre-approve the CT scan. You say that the records provided support the need for the requested CT scan The Plan denied your request. The Plan says the information sent in does not show details about the treatment that has been tried.
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 CT scan. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee has chronic low back pain and lumbar radiculopathy. There was no documented explanation as to why magnetic resonance imaging (MRI) was not ordered instead, why contrast was needed, or why physical therapy was not trialed first prior to consideration of imaging. No acute signs or symptoms were noted to suggest a red flag diagnosis. Therefore, without sufficient support made for this request, the CT will be considered not medically 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 CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve computed tomography (CT) scan services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on May
3, 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 must 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 May 3,
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the immediate upper denture (D5130),
and immediate lower denture (D5140) provided on November 20, 2020.

You asked the Plan to pay an additional amount for the dental services. You say that you cannot afford to pay
any additional amount for the dentures. The Plan denied your request. The Plan says up to $1,000 per year is
covered for comprehensive dental services. The Plan also says that the benefit limit has been exceeded.

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 and the services are listed as covered,
the benefit limit has been exceeded. The record shows that the Plan paid $1,030 for the dental services that you
received on November 20, 2020. Therefore, we decided that the Plan does not have to pay an additional amount
for the immediate upper denture (D5130), and immediate lower denture (D5140) provided on November 20,
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the gingival irrigations (D4921) provided on July 26, 2021.
You asked the Plan to pay for the gingival irrigations. You say that these procedures were necessary because
you had an infection in your mouth, and you suffer from a heart condition. You also say that if this procedure
was not done, the infection could have spread to your heart. The Plan denied your request. The Plan says
basic/major dental services are not covered under your 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 pay for the
gingival irrigations (D4921) provided on July 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on June 15, 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 June 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services you received from April 16, 2021, to April 19, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not covered.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the chiropractic services you received from April 16, 2021, to April 19, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on May 22, 2021, to May 27, 2021.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you are unable to pay the current balance at this time. The Plan denied your request. The Plan says the copayment you are being charged is correct.
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 $160 copayment per day, for days 1 to 7 for inpatient hospital care.
You have been asked to pay a $160 copayment per day for inpatient hospital care. The records show that you were inpatient for five (5) days, therefore, your total cost share is $800 ($160 x 5 days = $800). The EOC confirms $160 per day, is the required copayment for this service. 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 on May 22, 2021, to May 27, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services provided on May 13, 2021, by an out-of-network provider.

You asked the Plan to pay for imaging services. You say that the services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for out-of-network care have not been met.

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 imaging services provided on May 13, 2021, by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for incontinence supplies provided on April 3, 2021.

You asked the Plan to pay for incontinence 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 pay for incontinence supplies provided on
April 3, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment without transport (A0998) provided on September 2, 2020.
You asked the Plan to pay for the ambulance response without transport. You say that you are frustrated with the information you have been provided regarding this bill and feel the Plan should pay for the service due to the misleading information related to how the claim was processed. You were told this was denied due to a billing issue and the enrollee is not responsible for the cost but is continuously being billed by the provider. The Plan denied your request. The Plan says the ambulance benefit is a transportation benefit. When no transportation is provided, there is no payable service.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on September 2, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Documentation shows that the enrollee declined transport at the time of service as they were feeling better after treatment, and a release form was signed. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment without transport (A0998) provided on September 2, 2020.
Your complaint about potential confusion related to the way the claim was processed by the Plan is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from April 27, 2021, to May 26, 2021.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee's condition did not require daily skilled services at an inpatient skilled nursing facility (SNF) level of care.
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 pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on 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 the skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from April 27, 2021, to May 26, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on June 18, 2021.

You asked the Plan to pay for subsequent nursing facility care. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for subsequent nursing facility care provided on June 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2310, K0108) for the enrollee.

You asked the Plan to pre-approve the accessories. You say that this is medically necessary. 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 accessories. Our reviewer says that the requested accessories are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee's strength and function in the left upper extremity is 4/5, which supports that the enrollee can control any power options through their own individual switches. The privacy flap (K0108) does not serve a primarily medical purpose, and is therefore not medically 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 accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2310, K0108) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller with harness and electronic connection for a power wheelchair (PWC).

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 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the documentation does not reveal that the enrollee requires 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.) The patient does not need to operate three 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. The enrollee's strength and function in the upper extremities with the ability to feed himself indicates that the enrollee 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller with harness and electronic connection for a power wheelchair (PWC).