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

We decided that the Plan has to pre-approve a mouth guard (E1399).

You asked the Plan to pre-approve the mouth guard. You say that a mouth guard is medically necessary. The Plan denied your request. The Plan says that you do not meet criteria for coverage of a mouth guard.

The Plan must follow Medicare rules. The rules say that Medicare covers treatment for TMJ syndrome only when the condition or symptom is medical in nature. The treatment must also be medically 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 this item. Our reviewer says that a mouth guard is medically reasonable and necessary. Our physician reviewer found that the documentation supports the billed diagnosis of myalgia of the facial muscles which is attributable to multiple factors afflicting the temporomandibular joint. Affected muscle groups were noted in the records and topical ice spray eliminated symptoms temporarily when nerve conduction was reduced allowing for a supported diagnosis. The oral orthotic is focused on treating the medical condition of myalgia, which is affecting the muscles in the area of the jaw, a medical condition. The treatment is not directed at treating the structures that support the teeth. The appliance allows the musculature to relax and reduce the symptomatic myalgia. The documentation provided supports the contention that the treatment is reasonable and necessary. The surgical aspect of treatment was approved and the oral orthotic will serve to stabilize and decompress the joint and aid in allowing the muscles to relax and reduce or eliminate the myalgia. The documentation supports that the oral orthotic is medically appropriate for you. The suggested treatment plan includes an oral appliance as part of the overall treatment for the reduction of myalgia of the facial musculature associated with the temporomandibular joint. Muscle involvement was diagnosed with clinical examination and ice spray testing. Oral appliances have been shown to be reasonably effective in reduction of facial myalgia and is commonly used for this purpose.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this item have been met. Therefore, we decided that the Plan has to pre-approve a mouth guard (E1399).

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the sterile gauze provided on December 9, 2020.

You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the payment for this service is bundled into the payment for other covered services.

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 A6219 is gauze, non-impregnated, sterile, pad size 16 sq. in. or less, with any size adhesive border, each dressing. We find that CPT code A6219 is a bundled procedure. Payment for it is bundled into the payment for the physician service to which it is incident. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the sterile gauze provided on December 9, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cranial nerve stimulator placement (64568, 95976, 0266T).

You asked the Plan to pre-approve the cranial nerve stimulator placement. You say that the stimulator is 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 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 cranial nerve stimulator placement. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device does not have sufficient large studies to support its use for the enrollee's condition. Higher quality evidence is needed to help support general use for this condition. Therefore, this request for the Baroflex cranial nerve stimulator will be considered not 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 the cranial nerve stimulator placement have not been met. Therefore, we decided that the Plan does not have to pre-approve a cranial nerve stimulator placement (64568, 95976, 0266T).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis (D1110) provided on October 29, 2020.

You asked the Plan to pay for the dental service. You say that you get 3 cleanings per year. You also say that you did not exceed the frequency limit. The Plan denied your request. The Plan says coverage for prophylaxis is limited to twice per plan year. The Plan says that the frequency limit for this service has been exceeded.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage and prophylaxis is a covered service, the frequency limit has been exceeded. The record shows that the Plan paid for prophylaxis that you received on February 28, 2020, and June 30, 3030. Therefore, we decided that the Plan does not have to pay for the prophylaxis (D1110) provided on October 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an erectile dysfunction pump.

You asked the Plan to pre-approve the pump. You say that this was prescribed by your doctor. The Plan denied your request. The Plan says this is not covered for any condition.

The Plan must follow Medicare rules. Medicare rules and plan contract rules state that erectile dysfunction pumps are not covered.

The requested pump is never covered by the plan. Based on this information, we decided that Medicare rules for coverage of the pump have not been met. Therefore, we decided that the Plan does not have to pre-approve an erectile dysfunction pump.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone graft (21210) provided May 22, 2020.

You asked the Plan to pay for the bone graft following a tooth extraction. You say that you would like the service covered under your medical plan. The Plan denied your request. The Plan says the service performed was dental in nature and since you do not have supplemental dental benefits, it is not covered.

Medicare generally does not cover dental services. The Plan follows the same rule. 

The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the bone graft (21210) provided May 22, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening (71271).

You asked the Plan to pre-approve the requested LDCT scan. You say that the CT scan is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung cancer screening for enrollees who meet all the above criteria. 

We reviewed the file and the Medicare rules. We find that the record does not show a 30 pack-year smoking history. Therefore, we decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening (71271).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prosthetic protective cover (L5964).

You asked the Plan to pre-approve the protective cover. You say that the special cover 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 protective outer surface covering systems are 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 protective cover. Our reviewer says that the requested cover is not medically necessary. Our physician reviewer found the documentation does not indicate that the enrollee requires the prosthesis to be protected from unusually harsh environmental conditions beyond the provided protection afforded by the elements of the prosthesis. 

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 protective cover have not been met. Therefore, we decided that the Plan does not have to pre-approve a prosthetic protective cover (L5964).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the urgent care visits and the x-ray provided October 3, 2020, to October 22, 2020.

You asked the Plan to waive the copayments for the urgent care visits and the x-ray. You say that you are appealing these copayments. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing 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 each urgently needed visits in a non-contracted Urgent Care Center or walk-in clinic in the United States and a $30 copayment for each Medicare-covered standard x-ray service.

You have been asked to pay a $40 copayment for the urgent care visits on each date of service and a $30 copayment for the x-ray on October 16, 2020. The urgent care visits fall within the "Urgently Needed Services" benefit category. The x-ray falls 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 copayments for the urgent care visits and the x-ray provided from October 3, 2020, to October 22, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve a bioimpedance spectroscopy, extracellular fluid analysis for lymphedema assessment (93702 x 8 visits).

You asked the Plan to pre-approve these services. You say that these services are medically necessary for the enrollee. The Plan denied your request. The Plan says that these services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 these services. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found that a bioimpedance spectroscopy is considered a standard of care in the diagnosis and follow-up of lymphedema associated with breast cancer treatment. This patient with a previous right breast cancer and now a new right breast cancer is at high risk for lymphedema. The services are reasonable and medically necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pre-approve a bioimpedance spectroscopy, extracellular fluid analysis for lymphedema assessment (93702 x 8 visits).

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Freestyle Libre device for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medicaly necessary. The Plan denied your request. The Plan says this is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation that the enrollee is adjusting insulin doses at meals based on blood glucose levels.

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 the Freestyle Libre device for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cardiac Computed Tomography (CT) scan (75571).

You asked the Plan to pre-approve the CT scan. You say that the service is medically necessary. The Plan denied your request. The Plan says this type of scan is not supported for screening purposes.

The Plan follows Medicare rules. Medicare rules say that Cardiac Computed Tomography (CCT) and Coronary Computed Tomography Angiography (CCTA) are never covered for screening, i.e., in the absence of signs, symptoms or disease. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the CT scan. Our reviewer says that the requested CT scan is not medically necessary. Our physician reviewer found the use of CT cardiac calcium scoring to risk stratify has not consistently been shown in current literature to lead to significantly improved outcomes in individuals. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a cardiac Computed Tomography (CT) scan (75571).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a core buildup, including any pins when required (D2950).

You asked the Plan to pre-approve the core buildup. The Plan denied your request. The Plan says this service is not covered under the enrollee's benefit plan.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a core buildup, including any pins when required (D2950).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prosthetic lower limb with K3 features (L5814, L5845).

You asked the Plan to pre-approve the prosthetic lower limb with K3 features. You say that the advanced K3 features are 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 coverage is extended only if there is sufficient clinical documentation of functional need for the technologic or design feature of a given type of foot. 

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 prosthetic lower limb with K3 features. Our reviewer says that the requested prosthetic is not medically necessary. Our physician reviewer found there are no physician or therapist notes that show the need for K3 level. Physician and therapist notes do not indicate why replacement K2 components cannot be used. 

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 prosthetic lower limb with K3 features have not been met. Therefore, we decided that the Plan does not have to pre-approve a prosthetic lower limb with K3 features (L5814, L5845).
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve a core build up and crown (D2950 and D2752) on tooth # 7.

You asked the Plan to pre-approve a core build up and crown (D2950 and D2752) on tooth # 7. You say that the requested core build up and crown (D2950 and D2752) on tooth # 7 are medically necessary. The Plan denied your request. The Plan says that the requested core build up and crown (D2950 and D2752) on tooth # 7 are 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 a core build up and crown (D2950 and D2752) on tooth # 7 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 a core build up and crown (D2950 and D2752) on tooth # 7. Our reviewer says that the requested core build up and crown (D2950 and D2752) on tooth # 7 are medically necessary. Our physician reviewer found review of the enrollee's dental record and radiographs indicate the presence of large mesial caries undermining the mesio-incisal angle. A core buildup and crown are medically reasonable and necessary to restore the tooth to good function. Tooth #7 meets the criteria for coverage of significant coronal breakdown due to caries, for placement of a core buildup (D2750) and crown restoration (D2752).

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 a core build up and crown (D2950 and D2752) on tooth # 7 have been met. Therefore, we decided that the Plan has to pre-approve a core build up and crown (D2950 and D2752) on tooth # 7.

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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 87640, 87581, 87486, 87633) provided to the enrollee on October 15, 2020.

You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied your request. The Plan says the provider did not submit progress notes that are needed in order to determine the clinical utility of the testing.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Review of the records shows that no clinical information was provided to verify if the services were necessary. Therefore, we decided that the Plan does not have to pay for the laboratory services (CPT code(s): 87640, 87581, 87486, 87633) provided to the enrollee on October 15, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) services provided on October 27, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the services provided. You say that you rely on the facility to obtain the authorization. The Plan denied your request. The Plan says the services were not urgent, emergent, or approved in advance.

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 to 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 pay for the magnetic resonance imaging (MRI) services provided on October 27, 2020 by an out of network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit and advance care planning provided on July 21, 2020.

You asked the Plan to pay for the domiciliary or rest home visit and advance care planning. You say that the services were medically necessary and provided in good faith. 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 enrollee's terminal condition.

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 the domiciliary or rest home visit and advance care planning provided on July 21, 2020.