Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment of sacral meningeal/Tarlov cyst(s) with sacral lamina reconstruction.
You asked the Plan to pre-approve treatment of sacral meningeal/Tarlov cyst(s) with sacral lamina reconstruction. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, 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 treatment of sacral meningeal/Tarlov cyst(s) with sacral lamina reconstruction. 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 of a recent trial and failure of physical therapy (PT). There are no severe neurologic deficits noted. Surgery is not needed 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 treatment of sacral meningeal/Tarlov cyst(s) with sacral lamina reconstruction have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment of sacral meningeal/Tarlov cyst(s) with sacral lamina reconstruction.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested physician's services.
You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says you
must receive care from in-network providers with the exception of emergency or urgent care, dialysis while
temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which
requires prior authorization from the plan.
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 the
requested physician's services.
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 the durable medical equipment is medically necessary. 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 the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of orthotics for the enrollee's condition. The records do not show that the inserts are medically necessary for a brace to work. 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 foot, insert, removable, molded to patient model, longitudinal arch support, each (L3010) and orthopedic footwear, ladies shoe, depth inlay, each (L3216).
You asked the Plan to pre-approve foot orthotics. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.
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. The requested items are not an integral part of a covered leg brace. Therefore, we decided that the Plan does not have to pre-approve foot, insert, removable, molded to patient model, longitudinal arch support, each (L3010) and orthopedic footwear, ladies shoe, depth inlay, each (L3216).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for spinal manipulation (98940) and electrical stimulation
(G0283) provided from November 13, 2019 to December 12, 2019.
You asked the Plan to pay for spinal manipulation and electrical stimulation. You say that these services were
medically necessary. The Plan denied your request. The Plan says these services processed correctly.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation. The rules also 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 $20 copayment for Medicare
covered chiropractic services.
The records show that the electrical stimulation at issue is not manual manipulation of the spine. You have also
been asked to pay $20 for each spinal manipulation service, a Medicare covered chiropractic service. 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 pay for spinal manipulation (98940) and electrical stimulation (G0283) provided from
November 13, 2019 to December 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CPAP device.
You asked the Plan to pre-approve a CPAP device (E0601). You say that you realized you need a CPAP again. The Plan denied your request. The Plan says there is no recent sleep study or recent report that shows your use of a CPAP.
The Plan must follow Medicare rules. There is no current sleep test documentation to support medical necessity. There is no documentation showing continued use of the original CPAP device. Medicare rules say that items and services that are not medically necessary are not covered.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a CPAP device (E0601) have not been met. Therefore, we decided that the Plan does not have to pre-approve a CPAP device.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee is receiving an oral antibiotic for pneumonia, while being monitored for complications of COVID-19. The enrollee is ambulatory and eats and toilets on his own. The enrollee does not have documented skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs, as a practical matter, can be provided at a lower level of care. 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 care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for dialysis procedures (90945) provided from January 1, 2020 to January 31, 2020.
You asked the Plan to waive the coinsurance for dialysis procedures. You say that you should not be charged for these services because you and your wife did them. The Plan denied your request. The Plan says these services processed correctly.
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 20% coinsurance for outpatient renal dialysis services, medical equipment, and supplies. You have been asked to pay a 20% coinsurance for dialysis procedures. y 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 coinsurance for dialysis procedures (90945) provided from January 1, 2020 to January 31, 2020.
Your complaint about the services performed by the facility 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for comprehensive auditory evoked potentials (92585), basic vestibular evaluation (92540), electrocochleography recording (92584) and a comprehensive diagnostic evaluation (92588) provided on November 11, 2019.
You asked the Plan to pay for the testing services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the services billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 92585 is auditory evoked potentials for evoked response audiometry and/or testing of the central nervous system; comprehensive. The CPT Code Manual definition of code 92540 is basic vestibular evaluation, includes spontaneous nystagmus test with eccentric gaze fixation nystagmus, with recording, positional nystagmus test, minimum of 4 positions, with recording, optokinetic nystagmus test, bidirectional foveal and peripheral stimulation, with recording, and oscillating tracking test, with recording. The CPT Code Manual definition of code 92584 is Electrocochleography. The CPT Code Manual definition of code 92588 is distortion product evoked otoacoustic emissions; comprehensive diagnostic evaluation (quantitative analysis of outer hair cell function by cochlear mapping, minimum of 12 frequencies), with interpretation and report. We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the testing services. Our reviewer says that CPT codes 92585, 92540, 92584 and 92588 do not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records submitted do not clearly document the results and interpretation of these services.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for comprehensive auditory evoked potentials (92585), basic vestibular evaluation (92540), electrocochleography recording (92584) and a comprehensive diagnostic evaluation (92588) provided on November 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a thoracolumbosacral orthosis (L0457) provided on
December 18, 2019.
You asked the Plan to pay for a thoracolumbosacral orthosis. You say that this should be covered. The Plan
denied your request. The Plan says there is no evidence of an established relationship between the member and
the ordering physician.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services,
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for
telehealth services only if they are presented from an authorized originating site located in either a county
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located
in a rural census tract.
A review of the file does not show that the telehealth service was provided in an authorized originating site.
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are
likewise noncovered. Therefore, we decided that the Plan does not have to pay for a thoracolumbosacral
orthosis (L0457) provided on December 18, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for screening testing provided on November 9, 2019.
You asked the Plan to pay for screening tests. You say that the referring provider should have obtained prior
authorization before sending you the sample. The Plan denied your request. The Plan says the denial of
payment for these services is correct, because the ordering provider is out-of-network with the Plan and there is
no documentation that this testing was in relation to a specific symptoms or treatment.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.
There is no evidence that the testing was ordered by the enrollee's treating physician in relation to specific
signs or symptoms, or that the results were requested to guide therapeutic decision-making. Medicare does not
cover these tests solely for screening purposes. Therefore, we decided that the Plan does not have to pay for
screening testing provided on November 9, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental implants you received for teeth #3 and #4 on December 18, 2019.
You asked the Plan to pay for the implants. You say that this should be covered at 50%. The Plan denied your request. The Plan says this service is not covered for posterior teeth.
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 services are subject to a benefit limitation. The plan covers dental implants only for anterior (front) teeth. The requested implants replaced two posterior (back) teeth. Implants are not covered for back teeth. Therefore, we decided that the Plan does not have to pay for the dental implants you received for teeth #3 and #4 on December 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve wheelchair component or accessory, transit option (K0108).
You asked the Plan to pre-approve the wheelchair component or accessory. You say that the prior authorization for manual wheelchair accessories were denied not medically necessary and you are respectfully requesting an appeal of the denial for all items. The Plan denied your request. The Plan says a transit kit is only used for travel and is not used inside your home and is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Medicare only covers wheelchair accessories when they are used for a medical need to treat an illness or injury inside your home. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the wheelchair component or accessory have not been met. Therefore, we decided that the Plan does not have to pre-approve wheelchair component or accessory, transit option (K0108).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee by a chiropractor from November 6, 2019 to November 21, 2019.
You asked the Plan to pay for the services provided. You say that the enrollee did everything she could to avoid surgery. The Plan denied your request. The Plan says services other than manual manipulation are not covered when performed by a chiropractor.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The file shows that the enrollee received an office visit (CPT Code 99202) and manual therapy (CPT Code 97140). The services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the services provided to the enrollee by a chiropractor from November 6, 2019 to November 21, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on February 28, 2019.
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 rendered services 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 testing at issue in this appeal was 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 February 28, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable spa.
You asked the Plan to pre-approve a portable spa. You say that the portable spa is medically necessary for your
arthritis, pain and physical therapy. The Plan denied your request. The Plan says whirlpools are not primarily
medical in nature
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 portable spa.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Dexcom G6 Continuous Glucose Monitoring System.
You asked the Plan to pre-approve a continuous glucose monitor. You say that the enrollee finger stick tests 12 times a day. The Plan denied your request. The Plan says the clinical documentation does not report the frequency of glucose testing.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor. We looked at the file and Medicare rules. There is no record of the insulin regimen or testing. Based on this information, we decided that Medicare rules for coverage of a continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 Continuous Glucose Monitoring System.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that you disagree with the Plan's denial of the charges and you were unaware that you needed to submit an appeal for the denial. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on April 12, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a twin bed.
You asked the Plan to pre-approve the twin bed. You say that you would like reconsideration because you
currently sleep on plywood which is causing you to lose sleep and causing issues with your immune system.
The Plan denied your request. The Plan says this service is denied because it is a convenience household item
and not medical in nature.
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 twin bed.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home health aide for bathing.
You asked the Plan to pre-approve the home health aide. You say that you would like reconsideration because the member is home alone all day and needs assistance with bathing. The Plan denied your request. The Plan says bathing is only covered when the member is receiving skilled nursing services at home.
The Plan must follow Medicare rules. Medicare rules say that custodial care is not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the home health aide have not been met. Specifically, bathing assistance is considered custodial care and not a covered benefit. Therefore, we decided that the Plan does not have to pre-approve a home health aide for bathing.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for comprehensive oral exam (D0150) and inhalation of nitrous oxide, anxiolysis analgesia (D9230) provided December 30, 2019.
You asked the Plan to pay for the dental services. You say that the benefit cannot be exhausted as you had no other services before December after receiving the approved pre-authorization. These should be paid because the Plan does not offer holistic dental. The Plan denied your request. The Plan says the oral exam request exceeds the frequency limitations. The $1,000 benefit maximum has been met.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for comprehensive oral exam (D0150) and inhalation of nitrous oxide, anxiolysis analgesia (D9230) provided December 30, 2019.