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

We decided that the Plan does not have to pre-approve an expandable controller, harness, and an electrical
connection 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 the enrollee's upper limb strength and function are adequate to be able to control
the power options using their own switches.
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 services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the documentation does not indicate that the enrollee requires a proportional input devices (e.g.,
mini, compact, or short throw joysticks, touchpads, chin control, head control, etc.) other than a standard
proportional joystick, a non-proportional input devices (e.g., sip and puff, head array, etc.). The enrollee does
not need to operate 3 or more powered seating actuators through the drive control. The enrollee does not need
an expandable controller to be able to operate one or more of the following: 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 documentation indicates the enrollee has
sufficient strength and function to control the power features 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 the accessories have not been met. Therefore, we decided that the Plan does not
have to pre-approve an expandable controller, harness, and an electrical connection for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the gingival irrigation procedures provided on November 18,
2019 and November 19, 2019.
You asked the Plan to pay for the gingival irrigation procedures. You say that all of your claims were filed outof-
network several times and incorrect coding took place. The Plan denied your request. The Plan says this
service is not a covered 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 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 irrigation procedures provided on November 18, 2019 and November 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye exam you had on November 4,
2019.
You asked the Plan to waive the copayment. The Plan denied your request. The Plan says you are responsible
for the cost share.
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 $50
copayment for each Medicare-covered exam to diagnose and treat diseases or conditions of the eye.
Review of the file shows that you had an eye exam on November 4, 20291. You have been asked to pay a $50
copayment for the exam. The exam falls within the vision care benefit category. This means that you have been
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have
to waive the copayment for the eye exam you had on November 4, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan.
You asked the Plan to pre-approve a CT scan. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the requested services are not medically necessary.
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 a CT scan. Our reviewer says that the
documentation does not support that the requested CT scan is medically reasonable or necessary. Our physician
reviewer found the enrollee's most recent calcium level is reported as 11.3 mg/dL in an office visit note of
March 19, 2020. The enrollee reports fatigue; no significant abnormality is reported on exam other than ear
canal cerumen. There is no report of any planned surgical procedure for the hyperparathyroidism. The
documentation does not support that the computed tomography scan of the neck with and without contrast is
medically reasonable and 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 a CT scan have not been met. Therefore, we decided that the Plan does not have
to pre-approve a computed tomography (CT) scan.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the root canal (D3310) provided on January 15, 2020.
You asked the Plan to pay for the dental service. You say that you were advised by a Plan representative that
although the dental rider was dropped for 2020, you would still have 50% coverage for dental and vision
services. You also say that you were not offered any other details as to what that meant. The Plan denied your
request. The Plan says the root canal is not specifically listed as 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 root canal is not among those
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the root canal (D3310)
provided on January 15, 2020.
Your complaint about being misinformed by a Plan representative 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for moderate sedation services (99152) provided on October 8,
2019.
You asked the Plan to pay for the moderate sedation services. You say that you would like reconsideration
based on the records submitted. The Plan denied your request. The Plan says the documentation submitted did
not indicate the presence of an independent trained observer to assist in the monitoring of the patient's level of
consciousness and physiological status.
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 provided by the
same physician or other qualified health care professional performing the diagnostic or therapeutic service that
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age
5 years or older.
We find that CPT code 99152 is not supported in the record. Specifically, the documentation submitted does
not indicate the presence of an independent trained observer. Based on this information, we decided that
Medicare rules for coverage of the moderate sedation services have not been met. Therefore, we decided that
the Plan does not have to pay for moderate sedation services (99152) provided on October 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgical dressings for unspecified wounds.
You asked the Plan to pre-approve surgical dressings. You say that you need supplies so you do not contract
another infection. The Plan denied your request. The Plan says you do not have a surgical wound, or a
surgically treated wound.
The Plan follows Medicare rules. Medicare rules say that surgical dressings are only covered under certain
medical indications.
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 surgical dressings. Our physician
reviewer found that you are reported to have a non-pressure, chronic ulcerative wound on the dorsum of your
foot. You have intermittently had infection related to this wound, but the documentation does not support a
current infection. There is no documentation of surgical services or debridement. Without support of the
documentation, the services are not considered medically necessary at this time.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of surgical dressings have not been met. Therefore, we decided that the Plan does
not have to pre-approve surgical dressings for unspecified wounds.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on January 29,
2020.
You asked the Plan to waive the copayment for laboratory services. You say that you disagree with the charges.
The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the
correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40
copayment for lab services.
You have been asked to pay a $40 copayment for laboratory services. Laboratory services fall within the
outpatient diagnostic tests and therapeutic services and supplies benefit category. 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 laboratory services provided on January 29, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic radiology services provided on October 23, 2019.
You asked the Plan to pay for the diagnostic radiology services. The Plan denied your request. The Plan says
that the Plan requires utilization of network providers when possible and available, and requires authorization
for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency
situation, has been documented.
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
diagnostic radiology services. 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 diagnostic radiology services provided on October
23, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 24, 2019 by a
non-participating provider.
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 the services were rendered by a non-participating 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 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. 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 the medical services provided on September 24,
2019 by a non-participating provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your
request. The Plan says the enrollee has not had at least four-weeks of a regular, daily, multiple-hour usage of
basic compression 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 device. Our reviewer says that the
requested device is not considered medically reasonable and necessary in this case. Our physician reviewer
found there is no clinical documentation in the physical exam either by the physician or the treating therapist
that there is any extension of lymphedema of the chest, trunk, or abdomen. The enrollee does not have unique
characteristics that would indicate the segmented pump over a standard pump. There is documentation of a trial
and failure of the standard pump. However, it was just one time, and she stopped using it due to exacerbations
of symptoms, as noted in the addendum. The trial did not last four weeks, which is a requirement.
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 device have not been met. Therefore, we decided that the Plan does not have
to pre-approve a pneumatic compression device for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on January 30, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.
The laboratory services at issue in this appeal were requested solely for screening purposes. Medicare does not
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the
laboratory services provided on January 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services rendered on December 5,
2019.
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 also
performing a procedure, 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 documentation of
an independent trained observer to monitor the enrollee's level of consciousness and physiological status. 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
December 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-referral circle
provider.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your
request. The Plan says rheumatology services are available from providers in the referral circle.
Medicare rules say that plans can require enrollees to get care from specific network providers. The contract
with the Plan says that the Plan has to pre-approve care from out-of-referral circle 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 your PCP's referral circle. The Plan has
referral circle 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-referral circle provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for the chiropractic manipulative treatment (98940) rendered by an out of network (OON) provideron December 9, 2019.
You asked the Plan to issue reimbursement for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were provided by an out 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 has network providers available who can provide 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 issue reimbursement for the chiropractic manipulative treatment (98940) rendered by the out of network (OON) provider on December 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to a neurosurgeon outside of your referral circle.
You asked the Plan to pre-approve these services. You say that you have a family friend that went to see this provider with the same condition. The Plan denied your request. The Plan says the services are available from providers within the referral circle.
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 provider within your referral circle. The Plan has providers within your referral circle 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 a neurosurgeon outside of your referral circle.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse for CPAP purchased on April 29, 2019.
You asked the Plan to reimburse for the DME. You say that you should be reimbursed for a CPAP that you purchased out-of-pocket. The Plan denied your request. The Plan says prior authorization was not obtained prior to your purchase.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The Plan reviewed the call you made to their Member Service Department on April 22, 2019, and confirmed that you were advised a new sleep study would need to be completed and you were also advised that the sleep study can be completed at home. The Plan obtained your medical record from the office of the physician which states you advised the office you were going to pay out of pocket for the CPAP at which point a prescription was written. The Plan spoke with the provider and they were advised that you did not provide any insurance information at the time of purchase, and your purchase is listed as a self-pay purchase. Per your 2019 EOC, under DME and related supplies, it states that prior authorization may be required. Therefore, your claim for a CPAP machine purchased from the provider on April 29, 2019, processed correctly, as prior authorization was not obtained prior to your purchase. 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 reimburse for CPAP purchased on April 29, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on March 25, 2019.
You asked the Plan to pay for the dental services. You say that you are requesting reimbursement of services rendered. The Plan denied your request. The Plan says the service is not a covered benefit under the 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. Periodontal Maintenance is not included in your dental benefit, nor is it considered a preventative dental service. Periodontal Maintenance is not a preventative cleaning because it is considered a deep cleaning, scaling or root planing to remove bacteria, calculus (tartar), and debris that has collected under the gum. Therefore, we are unable to approve your request. Therefore, we decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on March 25, 2019.