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

We decided that the Plan does not have to pre-approve a walk-in tub.
You asked the Plan to pre-approve walk-in tub. You say that the enrollee's doctors feel she needs a walk-in tub due to her age and health. The Plan denied your request. The Plan says this item is not primarily medical in nature and is not covered by Medicare.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a walk-in tub.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that your right leg is shorter than your left. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable power wheelchair controller (E2377) with related controller harness (E2313), and the electronic connection between power seating systems (E2311).
You asked the Plan to pre-approve the expandable controller and related hardware. You say that it is felt that the requested items should be approved in full. The Plan denied your request. The Plan says the expandable controller is not medically necessary for the enrollee to use this device.
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 expandable controller and related hardware. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found The documentation does not reveal that the patient 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 3 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 patient's strength in the upper extremities and need for a powered wheelchair so that she is able to complete activities of daily living, including toileting, bathing, dressing, grooming, feeding, and preparing meals supports that the patient can control any power options through their 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 the expandable controller and related hardware have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable power wheelchair controller (E2377) with related controller harness (E2313), and the electronic connection between power seating systems (E2311).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve deep sedation/general anesthesia - first 15 minutes (CPT code D9222).
You asked the Plan to pre-approve the dental services. You say that you need the services as soon as possible. You state you are in bad health condition and require the anesthesia to be administered at a hospital in order to receive the dental services. The Plan denied your request. The Plan says the service or item in question is not covered under your contract under any normal circumstances.
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. This service is not listed in your handbook as a covered benefit; therefore, it is not covered. Therefore, we decided that the Plan does not have to pre-approve deep sedation/general anesthesia - first 15 minutes (CPT code D9222).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for HPV testing (CPT code G0476) provided on March 10, 2021.
You asked the Plan to pay for the testing. You say that you have had uterine cancer and are checked every six (6) months at this provider. You state this involves bloodwork, papsmear and physical exam. The Plan denied your request. The Plan says you have limited benefits for cervical and vaginal cancer screening; therefore, HPV Testing is once every five (5) years, in conjunction with the Pap test.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The plan has already paid for one HPV Testing which is limited to every five (5) years for date of service November 02, 2018. This benefit was paid on November 29, 2018. The health plan contract says for asymptomatic women between the ages of 30 and 65: HPV Testing once every five (5) years, in conjunction with the Pap test. Therefore, we decided that the Plan does not have to pay for HPV testing (CPT code G0476) provided on March 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee. 
 
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee is not on intensive insulin therapy. 
 
The Plan must follow Medicare rules. Medicare rules say that a continuous glucose monitor is covered for 
enrollees who are treated with three or more insulin injections per day.  
The file shows that the enrollee has twice-daily insulin treatment. Based on this information, we decided that 
Medicare rules for coverage of the monitor have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a continuous glucose monitor for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network therapy provider.
You asked the Plan to pre-approve these services. You say that you do not want to see a network provider. The Plan denied your request. The Plan says the services are available from network providers.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral to an out-of-network therapy provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing (80307) rendered by the OON provider on June 24, 2020.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an of network provider, without 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal.
The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the drug testing (80307) rendered by the OON provider on June 24, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy services to be provided by the 
requested out-of-network provider. 
 
You asked the Plan to pre-approve physical therapy services to be provided by the requested out-of-network 
provider. You say that the in-network provider is 22 miles round trip from your house while the requested 
provider is about 8 miles round trip from your house. You say that driving the extra distance with one arm in a 
sling could be an issue. The Plan denied your request. The Plan says the Medicare network adequacy for is 45 
minutes or 30 miles. In this case, the in-network provider is well within the network adequacy as it is located 
10 miles from the member's home. Your Plan covers provider services outside of your network only when your 
medical needs cannot be met in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers.  
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers  
We decided that the Plan does not have to pre-approve physical therapy services to be provided by the 
requested out-of-network provider. 
 
You asked the Plan to pre-approve physical therapy services to be provided by the requested out-of-network 
provider. You say that the in-network provider is 22 miles round trip from your house while the requested 
provider is about 8 miles round trip from your house. You say that driving the extra distance with one arm in a 
sling could be an issue. The Plan denied your request. The Plan says the Medicare network adequacy for is 45 
minutes or 30 miles. In this case, the in-network provider is well within the network adequacy as it is located 
10 miles from the member's home. Your Plan covers provider services outside of your network only when your 
medical needs cannot be met in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers.  
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available and accessible who can provide the services at issue in this appeal. We found no exception that would 
require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-
approve physical therapy services to be provided by the requested out-of-network provider
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation mileage.
You asked the Plan to pre-approve additional routine transportation mileage. You say that the additional transportation mileage is necessary. The Plan denied your request. The Plan says the benefit has been exhausted. Therefore, coverage criteria have not been met.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers 24 one-way transportation trips when each one-way trip does not exceed 50 miles.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation mileage.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an immediate partial denture for the lower jaw (D5222). 
 
You asked the Plan to pre-approve the denture. You say that you were told your plan covers dentures and do 
not understand why they are now being denied. The Plan denied your request. The Plan says this specific type 
of denture is not covered by your dental 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 type of denture requested is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
immediate partial denture for the lower jaw (D5222).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee. 
 
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a continuous glucose monitor is covered if the 
enrollee is treated with multiple (three or more) daily insulin injections. The records in the case file show that the enrollee is treated twice daily with insulin injections. There is a 
requirement for three or more injections per day in order to cover the requested monitor. Based on this 
information, we decided that Medicare rules for coverage of the monitor have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 11 anterior fillings (D2332), 6 posterior fillings (D2393), a crown (D2750) for tooth # 18, and core build up (D2950) for tooth # 18.
You asked the Plan to pre-approve the dental services. You say that you have fillings that have popped out. You say that you have been dealing with it for a few years. You say that some areas of your mouth have decayed. You also say that you feel at least 3 fillings should be approved. The Plan denied your request. The Plan says 1 filling is covered per calendar year. The Plan says that the frequency limit has been reached. The Plan says that crown is not listed as a covered service. The Plan also says core build up is not listed as a covered service either.
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 filling is listed as covered, the frequency limit has been reached. The record shows that the Plan approved a filling for tooth # 10.
Additionally, the requested crown and core build up are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 11 anterior fillings (D2332), 6 posterior fillings (D2393), a crown (D2750) for tooth # 18, and core build up (D2950) for tooth # 18.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for pneumatic compressor, segmental home model without calibrated gradient pressure (CPT code E0651) and segmental pneumatic appliance for use with pneumatic compressor, full leg (CPT code E0667) provided to the enrollee on July 8, 2020.
You asked the Plan to pay for the DME. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not supported by the records.
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. Documentation submitted did not indicate the provider discussed the need for the billed supply code; therefore, the billed supply code cannot be verified. The Delivery Ticket submitted did not include the carrier's tracking number, nor did the Proof of Delivery include an order number or details to corroborate the Delivery Ticket submitted. Of note, the Proof of Delivery is not itemized to indicate the specific supplies; therefore, the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to pay for pneumatic compressor, segmental home model without calibrated gradient pressure (CPT code E0651) and segmental pneumatic appliance for use with pneumatic compressor, full leg (CPT code E0667) provided to the enrollee on July 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the surgical placement of implant body (D6010), 
connecting bar (D6055), prefabricated abutments (D6056), implant/abutment supported denture (D6115) and 
surgical implant index (D6190). 
 
You asked the Plan to pre-approve the surgical placement of implant body (D6010), connecting bar (D6055), 
prefabricated abutments (D6056), implant/abutment supported denture (D6115) and surgical implant index 
(D6190). You say that the provider grinded too much leaving you unable to be correctly fitted for or wear 
dentures. You say that the only option left is dental implants. 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 pre-approve the 
surgical placement of implant body (D6010), connecting bar (D6055), prefabricated abutments (D6056), 
implant/abutment supported denture (D6115) and surgical implant index (D6190).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve immediate maxillary denture (D5130) and immediate mandibular denture (D5140).

You asked the Plan to pre-approve immediate maxillary denture and immediate mandibular denture. You say that these dentures you have do not fit properly. The Plan denied your request. The Plan says the benefit for dentures has been exhausted at this time.

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 immediate maxillary denture and immediate mandibular denture once every five years.

We looked at the file and Medicare rules. In this case, the file indicates that you last received these denture services on April 26, 2021. As a result, the benefit for dentures has been exhausted. Based on this information, we decided that the Plan's rules for coverage of immediate maxillary denture and immediate mandibular denture have not been met. Therefore, we decided that the Plan does not have to pre-approve immediate maxillary denture (D5130) and immediate mandibular denture (D5140).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out-of-network referral for Botox injections. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are in-network providers that can render this 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an out-of-network referral for Botox injections.
Appeal type: Practitioner Services
Decision: Unfavorable

We decidedthat the Plan does not have to pay for the moderate sedation services rendered on November 16, 
2020. 
 
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 99152 is not supported. 
 
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 99152 is Moderate sedation services by physician 
requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of 
consciousness and physiological status, patient 5 years of age or older, first 15 minutes. 
 
We find that CPT code 99152 is not supported in the medical record. Specifically, there is no separate note for the conscious sedation to validate the services were provided. 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 pay for the moderate sedation services rendered on November 16, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy services to be provider by the 
requested out-of-network provider. 
 
You asked the Plan to pre-approve the physical therapy services. The Plan denied your request. The Plan says 
you must receive your care from a network provider. In most cases, care you receive from an out -of-network 
provider (a provider who is not part of our plan's network) will not be covered. 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 services. Therefore, we decided that the Plan does not have to pre-approve physical 
therapy services to be provider by the requested out-of-network provider.