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

We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2311, E2313, E2377) for the enrollee.

You asked the Plan to pre-approve the additional accessories. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.

The Plan follows Medicare rules. Medicare rules say that services are covered 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 additional accessories. Our reviewer says that the requested accessories are not medically reasonable or necessary. Our physician reviewer found based on the medical records provided, there is no documentation that the enrollee needs the electrical connection between the wheelchair controller and two or more motors (E2311), expandable controller (E2377) and harness (E2313). The records indicate that the enrollee is modified independent with upper body activities of daily living with 4-/5 bilateral upper extremity strength indicating adequate strength and function to control the power options with their own switches.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the additional accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2311, E2313, E2377) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2750) for tooth # 3.
You asked the Plan to pre-approve the dental service. You say that the crown for tooth # 3 is medically necessary. The Plan denied your request. The Plan says the requested crown for tooth # 3 is not medically necessary.
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. The Plan covers the dental service when the services are medically necessary and reasonable. 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 dental service. Our reviewer says that the crown is not medically necessary. Our physician reviewer found the provide documentation does not indicate there is clear damage to the tooth in question, and no indication for the requested procedure. Therefore, the reviewer found that there is no necessity for the crown for tooth # 3. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental service have not been met. Therefore, we decided that the Plan does not have to pre-approve a crown (D2750) for tooth # 3.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrocardiogram (EKG) rendered on January 22, 2021 and February 2, 2021.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 93000 is not separately payable.

The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.

The provider submitted a claim for procedure codes 93000 (electrocardiogram) and 11402 (excision of lesion). Code 93000 is a column II code with a modifier indicator of 1 when billed with column I code 11402. Code 93000 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the electrocardiogram (EKG) rendered on January 22, 2021 and February 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the unspecified preventive procedure (D1999), the intraoral -
periapical first radiographic image (D0220), the extraction (D7210), and the limited oral evaluation - problem
focused (D0140) received January 5 and 6, 2021.
You asked the Plan to pay for the dental services (D1999, D0220, D7210, D0140). You say that you told your
provider that your insurance would not pay for the requested services, but the provider performed the services
anyway. The Plan denied your request. The Plan says the requested services are not covered under your
supplemental 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 the
unspecified preventive procedure (D1999), the intraoral - periapical first radiographic image (D0220), the
extraction (D7210), and the limited oral evaluation - problem focused (D0140) received January 5 and 6, 2021.
Your complaint about your provider performing the requested services after you stated that your insurance
would not cover these services 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a conforming bandage (A6446).

You asked the Plan to pre-approve a conforming bandage. You say that this request is medically necessary for your condition. The Plan denied your request. The Plan says you do not have a qualifying wound that is a requirement for coverage.

The Plan follows Medicare rules. Medicare rules say that a conforming bandage requires a qualifying wound to be eligible for coverage. 

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 conforming bandage. Our reviewer says that the requested service is not medically reasonable and necessary. Our physician reviewer found you are a 70-year-old male with a history of diabetes mellitus and multiple arm abrasions with intermittent bleeding. Based on the medical records, you do not meet requirements for a qualifying wound that would allow coverage for the conforming bandage. The medical records indicate superficial arm abrasions with bleeding episodes sometimes but no indication of a surgically treated wound. 

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 conforming bandage have not been met. Therefore, we decided that the Plan does not have to pre-approve a conforming bandage (A6446).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CGM (CPT code K0554 and K0553), for the enrollee.
You asked the Plan to pre-approve the CGM. You say that the CGM is necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the CGM have not been met. The enrollee is not currently on insulin. There is no frequent adjustment of an insulin treatment regimen based on blood glucose monitor or CGM testing results. Therefore, we decided that the Plan does not have to pre-approve a CGM (CPT code K0554 and K0553), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for lumbar sacral orthosis (L0648) provided November 12, 2020.

You asked the Plan to pay for the orthosis. You say that this claim was denied without giving you the chance to submit medical records to justify level of service. The Plan denied your request. The Plan says the billed supply code cannot be verified, and the provider is not a Medicare certified DME supplier.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.

The record does not contain a valid physician order and proof of delivery for the supplies provided in this case. The delivery ticket submitted did not include the carrier's tracking number. The proof of delivery did not include an order number or details to corroborate the delivery ticket submitted. The proof of deliver is not itemized to indicate the specific supplies. The provider is also not a Medicare certified DME supplier and therefore is not eligible to receive payment. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for lumbar sacral orthosis (L0648) provided November 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the periodic oral evaluation (D0120)
and the prophylaxis (D1110) received September 2, 2020, from the out-of-network provider.

You asked the Plan to pay an additional amount for the dental services. You say that the Plan should pay for
the claim. The Plan denied your request. The Plan says you may be billed more by an out-of-network provider
if the charge is greater than maximum allowable charge.

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 payment is in excess of
those covered under this benefit. The Plan has agreed to cover up to 100% of the maximum allowable charge
(MAC) for the requested services. You have been asked to pay the difference between the Plan's MAC and
what was charged by the out-of-network provider. Therefore, we decided that the Plan does not have to pay an
additional amount for the periodic oral evaluation (D0120) and the prophylaxis (D1110) received September 2,
2020, from the out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional follow up visits by a non-contracted retina specialist.

You asked the Plan to pre-approve follow up visits with a non-contracted retina specialist. You say that you have been receiving care from this provider for a year and the doctor has been monitoring your condition and knows your case well. The Plan denied your request. The Plan says there is no indication to refer the member to the non-network ophthalmologist follow up when services are available in the Plan's network and you are contractually required to obtain service from network providers.

Medicare generally does not cover routine vision and eyewear services. Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care.

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 additional follow-up visits with a non-contracted retina specialist. Our reviewer says that it is not medically necessary for this care to be provided outside of the Plan's network. Our physician reviewer found that the enrollee has been consulting with an out-of-network (OON) specialist. The enrollee is not receiving active treatment as defined by Medicare rules. The Plan has in-network retina specialists. The elements of the coverage rule are not satisfied. The requested service cannot be recommended.

We looked at this physician's review, the file, and Medicare rules. In this case there is no specific clinical rationale for continued OON follow-up. The review has determined that it is not medically necessary for you to continue receiving follow-up care with the requested out of network specialist at this point in your treatment. Your care can be safely transitioned to an in-network provider. Based on this information, we decided that the Plan's rules for coverage of follow up visits with a non-contracted retinal specialist have not been met. Therefore, we decided that the Plan does not have to pre-approve additional follow up visits by a non-contracted retina specialist.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (81551) provided October 30, 2020.
You asked the Plan to pay for the genetic testing. You say that the genetic testing was medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that ConfirmMDx is covered for Males aged 40 to 85 years old that have undergone a previous cancer-negative prostate biopsy within 24 months and are being considered for a repeat biopsy. We looked at the file and Medicare rules. The record does not show a repeat biopsy is being considered. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (81551) provided October 30, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services from May 6, 2021 and beyond. You say that the enrollee needed the SNF services from May 6, 2021 to present. The Plan denied your request. The Plan says the enrollee's needs can be met at a lower 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 pre-approve SNF services from May 6, 2021 and beyond. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there is no documentation that the patient requires skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse are not required to safely and effectively provide medically necessary and reasonable treatment. This patient does not require skilled therapy services, i.e., the specialized skill, knowledge and judgment of a qualified therapist are not required to safely and effectively provide medically necessary and reasonable treatment. Based on the medical records provided daily skilled services are not required. This patient does not require the services on an inpatient basis, only in a skilled nursing facility 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 services from May 6, 2021 and beyond have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series x-ray (D0210) and the unspecified preventive service (D1999) provided on January 13, 2021.

You asked the Plan to pay for the dental services. You say that your dental office informed you that you were covered for the services that were performed. You say that you feel like you were taken advantage of. You also say that you are not capable of paying for such a dental bill. The Plan denied your request. The Plan says complete series x-ray is not listed as a covered service. The Plan says that unspecified preventive service is not listed as a covered service either. The Plan also says that the provider called on January 2, 2020 and was advised that complete series x-ray, specifically, is not a covered service.

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 complete series x-ray (D0210) and the unspecified preventive service (D1999) provided on January 13, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services provided on October 6, 2020.

You asked the Plan to pay for the ambulance services. 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
member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all
hospice care from the effective date of election to the date of discharge or revocation. During the election, feefor-
service Medicare also covers attending physician services and all care unrelated to the terminal illness until
the first day of the month following the month in which hospice was revoked or discharged.

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 ambulance services provided on October 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the immediate denture - mandibular (D5140), and the
extraction, erupted tooth or exposed root (D7140) received October 30, 2020.

You asked the Plan to pay for the dental services. You say that you have dental coverage and therefore, the
plan should pay for the claim. The Plan denied your request. The Plan says if you see an out-of-network dentist
you will be responsible for 100% of the cost.

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. The Plan does not provide coverage for dental services received outof-
network. Therefore, we decided that the Plan does not have to pay for the immediate denture - mandibular
(D5140), and the extraction, erupted tooth or exposed root (D7140) received October 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for wound debridement provided by an out-of-network provider on February 12, 2021.
You asked the Plan to pay for wound debridement. You say that the services were provided prior to obtaining authorization to avoid delay in care. You say that the services were medically necessary, and the claim should be processed for payment. The Plan denied your request. The Plan says in-network providers are required and were available to provide the service.
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 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 wound debridement provided by an out-of-network provider on February 12, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for nursing services (T1000) provided on August 28, 2020, and
August 30, 2020.

You asked the Plan to pay for nursing services. You say that these services were medically necessary. The Plan
denied your request. The Plan says these services were not billed with the correct number of units.

The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units
provided for each procedure code.

We find that 84 units of CPT code T1000 on August 28, 2020, and 71 units on August 30, 2020, are not
supported in the medical record. The medical record only supports 76 units of CPT code T1000 on August 28,
2020, and 70 units on August 30, 2020. Based on this information, we decided that Medicare rules for coverage
of nursing services have not been met. Therefore, we decided that the Plan does not have to pay for nursing
services (T1000) provided on August 28, 2020, and August 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis provided on December 21, 2020.
You asked the Plan to pay for the prophylaxis. You say that you believe this cleaning should be covered. The
Plan denied your request. The Plan says this service exceeds the benefit allowance.
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, you are limited to up to 2 prophylaxes
per calendar year. The record shows that you received prophylaxes on February 19, 2020, and July 4, 2020, and
your prophylaxis (cleanings) benefit had been exhausted. Therefore, we decided that the Plan does not have to
pay for the prophylaxis provided on December 21, 2020.