Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial periapical x-ray (D0220) and the additional periapical x-ray (D0230) provide.

You asked the Plan to pay for the dental services. You say that the services should be covered per your contract information.The Plan denied your request. The Plan says periapical x-rays are not listed as covered services.

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. Additionally, the record shows that you were disenrolled from the dental rider, effective January 30, 2020.Therefore, we decided that the Plan does not have to pay for the initial periapical x-ray (D0220) and the additional periapical x-ray (D0230) provide.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve disposable batteries for hearing aids (A9999).
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says these items are not a covered benefit under your contractual policy.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The items at issue in this appeal do not serve a purpose that is primarily medical in nature. These items are not covered by the Plan nor by Medicare. Therefore, we decided that the Plan does not have to pre-approve disposable batteries for hearing aids (A9999).
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve an upper eye lid surgery and eyebrow lift (15823, 67917).
You asked the Plan to pre-approve these services. You say that the requested procedures are medically necessary for the enrollee. The Plan denied your request. The Plan says that these procedures are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that blepharoplasty, blepharoptosis repair, and brow ptosis repair (brow lift) are surgeries that may be functional (to improve abnormal function) and therefore, are reasonable and 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 these services. Our reviewer says that the requested procedures are medically reasonable and necessary. Our physician reviewer found that the enrollee has evidence of a severe condition of his upper eyelids and brows. He has obvious functional impairment with visual obstruction. His Margin Reflux Distance was measured at 1 mm which is supported by a review of the photographs provided. Blepharoplasty and correction of his brow ptosis would likely improve and resolve his functional impairment. For the purposes of this policy, these surgeries (either individually or in the minimum combination required to achieve a satisfactory surgical outcome) are functional when overhanging skin or upper lid position secondary to dermatochalasis, blepharochalasis, blepharoptosis, or pseudoptosis is sufficiently low to produce a visually-significant field restriction considered by this policy to be approximately 30 degrees or less from fixation. Published literature correlates this amount of field restriction with a Margin Reflex Distance of 2.0 mm or less. Based on the documentation provided including review of the photographs, the enrollee has a severe functional impairment (visual obstruction) that would likely improve with surgical correction of both the upper eyelids and brows. He has a documented Margin Reflex Distance of 1 mm which is less than 2 mm. Photographs support his clinical scenario. Therefore, the requested procedures should be considered medically necessary as defined by Medicare. 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 been met. Therefore, we decided that the Plan has to pre-approve an upper eye lid surgery and eyebrow lift (15823, 67917).
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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services coded A0429 provided on August 22, 2020.You asked the Plan to pay forthe ambulance services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services were billed incorrectly.The Plan must follow Medicare rules. Medicare rules say that providers must reportservices correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code A0429 is ambulance service, basic life support, emergency transport (bls-emergency).We find that CPT code A0429 is not supported in the medical record. Specifically, code A0429 is not the appropriate code for billing Medicare when the enrollee is pronounced dead after the ambulance is called. Medicare requires the reporting of A0428 for services provided under these circumstances. Based on this information, we decided that Medicare rules for coverage of the ambulance services have not been met.Therefore, we decided that the Plan does not have to pay forthe ambulance services coded A0429 provided on August 22, 2020
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 services are medically necessary. The Plan denied your request. The Plan says the service is not medically necessary or reasonable.
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 the patient does not require services at the LTACH that are not already available at the current facility. 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. Specifically, the enrollee can receive the necessary care at the current facility. This means that LTACH is not reasonable or necessary. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean ablation procedure (36479).You asked the Plan to pre-approvethe ablation procedure. You say that the procedure is medically necessary.The Plan denied your request. The Plan says coverage criteria has not been met.The Plan follows Medicare rules. Medicare rules say that this procedure is only covered when 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 ablation procedure. Our reviewer says that the requested ablation procedure is not medically necessary. Our physician reviewer found documentation does not support the medical necessity of the additional perforator vein ablations. The patient had a venous stasis ulcer that healed following endovenous ablation and wound care. Currently there is no ulcer present although there are residual skin changes and concern for future skin ulceration. The health plan has also already approved the requested sclerotherapy. Endovenous ablation of the perforator veins is not as well studied as endovenous ablation of the saphenous veins and risks are higher.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 ablation procedure have not been met.Therefore, we decided that the Plan does not have to pre-approvean ablation procedure (36479)
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ear molds (V5264) provided on October 4, 2020.You asked the Plan to pay forthe ear molds. You say that you would like reconsideration because the ear molds are necessary for you to wear your hearing aids without discomfort.The Plan denied your request. The Plan says this is not a covered benefit.Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan does not pay for ear molds.We looked at your request, the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the ear molds have not been met. Specifically, the Plan does not pay for ear molds.Therefore, we decided that the Plan does not have to pay forthe ear molds (V5264) provided on October 4, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on February 4, 2020.
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 medical services provided to the enrollee by an out-of-network provider on February 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveoncology medical services to be provided by an out-of-network (OON) provider.You asked the Plan to pre-approveOON services. You say that you would like to see only female oncologists.The Plan denied your request. The Plan says your care can be safely managed by an in-network doctor.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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these OON services.Therefore, we decided that the Plan does not have to pre-approveoncology medical services to be provided by an out-of-network (OON) provider
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve) (CPT Code 64555).
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says Auricular stimulator is not covered by Medicare.
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 services have not been met. Medicare guidance says Auricular stimulator is not covered. Therefore, we decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve) (CPT Code 64555).
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the acupuncture services provided on November 12, 2020.
You asked the Plan to pay for the acupuncture services. You say that these services keep you pain free and would like these services to be covered. The Plan denied your request. The Plan says that that acupuncture services are not covered by a chiropractor.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case. We looked at the file and Medicare rules. Based on the information available to the public, the provider is a licensed acupuncturist and there is nothing in the EOC which would indicate that her services are excluded under the acupuncture benefit. Therefore, we decided that the Plan has to pay for the acupuncture services provided on November 12, 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services (CPT 99291) provided to the enrollee on August 17, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the records do not support the services billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99291 is "critical care visit of 30-74 minutes." We asked our coding 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our coding reviewer found CPT 99291 should be reported with documented time of the critical care visit. The documentation submitted did not include time spent during critical care services, therefore, this code cannot be verified. We looked at this coder'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 pay for critical care services (CPT 99291) provided to the enrollee on August 17, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea prostate rectal spacer placement(55874).You asked the Plan to pre-approvethe spacer placement. You say that the spacer is medically necessary.The Plan denied your request. The Plan says rules for coverage are not met.The Plan follows Medicare rules. Medicare rules say that a spacer is covered ONCE in patients with clinically localized prostate cancer that is a Low or Favorable Intermediate Prostate Cancer Risk.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 thespacer placement. Our reviewer says that the space placement is not medically necessary. Our physician reviewer found the record shows the patient has unfavorable intermediate risk prostate cancer. Medicare coverage criteria has not been met.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 spacer placement have not been met.Therefore, we decided that the Plan does not have to pre-approvea prostate rectal spacer placement(55874).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Vertiflex Superion Interspinous device for the enrollee.You asked the Plan to pre-approvethese services. You say that these services are medically necessary.The Plan denied your request. The Plan says that the clinical value and effectiveness of the Vertiflex Superion Interspinous device in the setting of severe lumbar spine stenosis, lumbar radiculopathy and post-laminectomy syndrome has not been demonstrated in the peer-reviewed literature.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 requested services are not considered medically reasonable and necessary in this case. Current evidence based medical guideline and peer reviewed literature do not fully support the spinal decompression device procedure over the 'gold standard' of lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollee's medical condition as discussed above. FDA indications include implantation of the Superion device at one or two adjacent lumbar levels in patients with moderate spinal stenosis in whom operative treatment is indicated at no more than two levels, from L1 to L5. Severe spinal stenosis is noted and is not a supported indication. Significant osteoporosis has not been ruled out in this middle aged patient. Scoliosis is evident and also a relative contraindication. Superion indirect lumbar decompression would not be considered the standard of care for the enrollee's medical condition. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for these services. 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-approvea Vertiflex Superion Interspinous device for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the durable medical equipment provided by an out of network (OON) provider.

You asked the Plan to pay for the services provided. You say that your doctor prescribed the cane after your recent operation.The Plan denied your request. The Plan says to receive payment for covered Medicare items, a provider must be enrolled in the Medicare program.

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 provider in this case is not a network provider with the Plan. The records do not show the provider is enrolled in the Medicare program. The Plan had network providers available who could have provided the cane at issue. The Plan did not pre-approve the cane. We found no exception that would require the Plan to pay for this cane.Therefore, we decided that the Plan does not have to pay for the durable medical equipment provided on September 8, 2020 by an out of network (OON) provider
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodontal scaling and root planing provided on November 26, 2019.
You asked the Plan to pay for the periodontal scaling and root planing. You say that The Plan denied your request. The Plan says the maximum coverage amount for the contract year had been met.
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 coverage is limited to $500 per calendar year. The records show that the Plan paid $500 toward the cost of dental services provided to you in 2019. The services in dispute exceeded that benefit maximum limitation. Therefore, we decided that the Plan does not have to pay for periodontal scaling and root planing provided on November 26, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to further reimburse you the prosthetic eye (V2623) provided on September 17, 2020, by an out-of-network (OON) provider.
You asked the Plan to further reimburse you the prosthetic eye. You say that you would like to be further reimbursed for the services you received. The Plan denied your request. The Plan says they are only responsible for the Medicare-approved amount.
The Plan must follow Medicare rules. Medicare rules say that the MAO must pay the difference between the enrollee's cost-sharing and the original Medicare limit charge. We looked at the file and Medicare rules. The file indicates that in this case the Plan has already paid the maximum allowable amount for the services rendered, the Medicare-approved amount. Although you are being charged a higher amount, this is specifically between you and the OON provider. The Plan has fully met its required reimbursement amount. Based on this information, we decided that Medicare rules for coverage of the prosthetic eye have not been met. Therefore, we decided that the Plan does not have to further reimburse you the prosthetic eye (V2623) provided on September 17, 2020, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan does not have to pay for eye refraction services provided on July 22, 2020.
You asked the Plan to pay for this service. You say that this service should be covered by the Plan. The Plan denied your request. The Plan says eye refraction is not covered. Maximus overturned the Plans denial. The Plan requested a reopen and stated that the Maximus decision was based on the idea that the eye exam benefit had not been exhausted. The Plan provided the Explanation of Benefits (EOB) that shows the Plan paid all of those services allowed by the vision benefit for this date of service. Medicare does not cover eye refractions. This service is bundled with a standard eye exam and is not paid to the provider separately.
The Plan is correct in this case. Medicare refraction services. 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 does not cover refraction services. Therefore, we decided that the Plan does not have to pay for eye refraction services provided on July 22, 2020.