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

We decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341) for all 4 quadrants.

You asked the Plan to pre-approve the dental services. You say that you need a root canal and a deep cleaning. The Plan denied your request. The Plan says periodontal scaling and root planing is not 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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341) for all 4 quadrants.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an occlusal guard (D9944).
You asked the Plan to pre-approve the occlusal guard. You say that you would like this service to be approved. The Plan denied your request. The Plan says this service is not covered under your 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 an occlusal guard (D9944).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Functional electrical stimulation (Bioness L300 GO system and supplies).

You asked the Plan to pre-approve Bioness L300. You say that the item is medically necessary. The Plan denied your request. The Plan says Functional nerve stimulator is not covered for diagnosis of stroke.

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 Bioness L300. Our reviewer says that the requested item are not considered medically reasonable and necessary in this case. Our physician reviewer found the member does have muscle atrophy, is not an SCI patient and has not received 32 physical therapy sessions with the device over a 3 month period. Your diagnosis (CVA) is not a covered indication for use of NMES.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Bioness L300 have not been met. Specifically, the item requested is not covered for your diagnosis. This means the item is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve Functional electrical stimulation (Bioness L300 GO system and supplies).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MRI of the arm joint/upper extremity for the enrollee.

You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your request. The Plan says the doctor did not show that there was a full course of treatment.

The Plan must follow Medicare rules. Medicare rules say that MRIs 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 the MRI. Our reviewer says that the requested MRI is not medically reasonable or necessary. Our physician reviewer found the enrollee had a positive physical exam, with a positive empty can test, which may be associated with rotator cuff pathology and or impingement. However, there is no history of weakness, numbness or tingling. The requesting physician has a plan for orthopedic referral which has not yet been done. The enrollee has been taking Tylenol which does not constitute the requirement to establish medical necessity as of yet for the requested MRI. No physical therapy has yet been attempted. Medical necessity without first attempting a six week trial of conservative therapy has not yet been established.

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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve MRI of the arm joint/upper extremity for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit (99212) to be rendered by the OON
provider.
You asked the Plan to pre-approve this service. You say that you would like to remain under the care of this
physician as he knows your urological history best. The Plan denied your request. The Plan says there are
equally qualified in-network providers available to provide the requested 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 provider at issue in this case is not a network provider with the Plan. 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 service. Our reviewer says that this service is not medically necessary.
Our physician reviewer found that it is not necessary to have this service provided by the out of network
Urologist that you have been receiving care from. In-network urologists are available to provide this care.
Management of benign prostatic hyperplasia (BPH) and monitoring of prostate-specific antigen (PSA) levels
are very common issues encountered by all urologists.
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 service have not been met. The Plan has network providers available who
can provide the service at issue in this appeal. We found no exception that would require the Plan to preapprove
this service. Therefore, we decided that the Plan does not have to pre-approve an office visit (99212)
to be rendered by the OON provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the unlisted neurological procedure.

You asked the Plan to pay for unlisted neurological or neuromuscular diagnostic procedure (95999). You say
that the Plan should pay this claim. The Plan denied your request. The Plan says this service is considered a
bundled procedure as the cost is included in the cost of the primary procedure.

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, we have confirmed that code
unlisted neurological or neuromuscular diagnostic procedure (95999) has a bundled relationship with the
primary procedure and cannot be paid as billed. This code cannot be paid as a separate line item. Train of Four
testing is not paid by Medicare separately. Based on the claim submitted, Medicare billing criteria have not
been met. Therefore, we decided that the Plan does not have to pay for the unlisted neurological procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on October 29,
2020.
You asked the Plan to waive the copayment for the office visit. You say that the appointment should have been
scheduled in the time frame that your post-op visits would have been covered. The Plan denied your request.
The Plan says the copayment applied 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 $30
copayment for a specialty physician.
You have been asked to pay a $30 copayment for the office visit. The office visit falls within the
"Physician/Practitioner services, including doctor's office visits" benefit category. The records show the office
visit was provided outside of the global period. 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 office
visit provided on October 29, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services (A0429) provided on April 12, 2020.
You asked the Plan to pay for the ambulance services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this is not reimbursable according to CMS billing guidelines.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code A0429 is not supported in the record. Specifically, when the member was pronounced dead after the ambulance is called, providers must report CPT code A0428 with modifier QL. Based on this information, we decided that Medicare rules for coverage of the ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance services (A0429) provided on April 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two additional intraoral periapical x-rays (D0230 x2).

You asked the Plan to pay for the additional intraoral periapical x-rays. You say that you would like this service to be covered. The Plan denied your request. The Plan says this service is allowed two times per calendar year. The Plan also says that you have reached this limit for this 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, intraoral x-rays and bitewings are limited to 2 of either codes D0220, D0230, D0270, D0272, D0273, or D0274 per calendar year. The record shows that you received bitewings (D0273) and a first intraoral periapical x-ray (D0220) and your intraoral x-rays and bitewings benefits have been exhausted. Therefore, we decided that the Plan does not have to pay for the two additional intraoral periapical x-rays (D0230 x2).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dexamethasone.
You asked the Plan to pre-approve Dexamethasone. You say that the medication is being used for chronic pain. The Plan denied your request. The Plan says Dexamethasone to be taken at home is not covered under the Part B benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Dexamethasone.
Benefits for Dexamethasone may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited oral exam (D0140).

You asked the Plan to pay for a limited oral exam. You say that you would like the Plan to reimburse you for
this service. The Plan denied your request. The Plan says that the claim processed correctly.

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 a limited
oral exam (D0140).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 360 skin barrier ostomy supplies (A4414).

You asked the Plan to pre-approve 360 skin barrier ostomy supplies. You say that the item should be covered. The Plan denied your request. The Plan says they have not received any clinical information as to document factors that necessitate your request for more than the usual maximum quantity of skin barrier ostomy supplies.

The Plan must follow Medicare rules. 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 360 skin barrier ostomy supplies have not been met. Specifically, there is no explanation in the medical records indicating the necessity to have more than the maximum allowed for this item. This means the item is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve 360 skin barrier ostomy supplies (A4414).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller with harness and electronic connection for a power wheelchair (PWC).

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. Medicare rules say that PWC accessories are covered when specific criteria are met.

We looked at the file and Medicare rules. The file does not show that the expandable controller with harness and electronic connection are required, as the enrollee's level of function is adequate to control the power options with the approved switches. Therefore, we decided that the Plan does not have to pre-approve an expandable controller with harness and electronic connection for a power wheelchair (PWC).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the duplex scans provided on October 6, 2020.
You asked the Plan to waive the copayment for the duplex scans. You say that you confirmed that you did not want to see a provider who was not within the network. The Plan denied your request. The Plan says the claims were processed at the in-network level and 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 $160 copayment for each in-network Medicare-covered radiological diagnostic service, not including x-rays, performed in a physician's office or at a free-standing facility (such as a radiology center or medical clinic). You have been asked to pay a $287.81 copayment for the duplex scans. The duplex scans fall within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. See chart below.
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 duplex scan of the vena cava and the duplex scan of the extremities provided on October 6, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered from December 13, 2019 to December 31, 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 the claims were billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that home health claims must be billed with the appropriate HIPPS code. We looked at the file and Medicare rules. The file shows that the claims were not billed with a valid HIPPS code. 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 home health services rendered from December 13, 2019 to December 31, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided on August 25, 2020.
You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because Medicare denies coverage for all cardiovascular risk assessment panels - except the basic lipid panel - for symptomatic patients with suspected or documented cardiovascular disease.
The Plan follows Medicare rules. Medicare rules state that molecular pathology procedures may be covered when all of the above criteria are met. 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 pay for genetic testing. Our reviewer says that this testing does not meet the Medicare criteria for coverage. Our physician reviewer found that the enrollee's condition should be investigated using clinical testing for recurrent obstructive coronary artery disease and cardiac rhythm disturbances. The use of molecular genetic investigations for this is not medically necessary in an elderly patient with known established disease and active symptoms and will not add to the management
options. In addition, alternative clinical testing is readily available for further refinement of the enrollee's diagnosis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing provided on August 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal scaling and root planing (1-3 teeth per quadrant) for two quadrants (D4342 x2) provided on November 20, 2020.
You asked the Plan to pay for the periodontal scaling and root planing for 1-3 teeth per quadrant. You say that this was a necessary service. The Plan denied your request. The Plan says they only cover certain specific dental services. Periodontal scaling and root planing for 1-3 teeth per quadrant (D4342) is not covered by your supplemental dental 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 pay for the periodontal scaling and root planing (1-3 teeth per quadrant) for two quadrants (D4342 x2) provided on November 20, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xarelto.

You asked the Plan to pre-approve Xarelto. You say that the enrollee has been poorly controlled on warfarin in the past. The Plan denied your request. The Plan says this medication does not fall under Part B.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Xarelto.

Benefits for Xarelto may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the tetanus vaccine (90715).

You asked the Plan to pay for the tetanus vaccine. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this vaccine is not covered under Medicare Part B.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the tetanus vaccine. The Plan follows the same rules. 

Records do not show that you have been injured or directly exposed to any illness related to the tetanus vaccine. Therefore, we decided that the Plan does not have to pay for the tetanus vaccine (90715).

Benefits for the tetanus vaccine may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for wound debridement provided on November 20, 2020.
You asked the Plan to waive the copayment for wound debridement. You say that the copayment should not apply for continuing care. You say that the cost is not affordable. The Plan denied your request. The Plan says the copayment applied 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 $250 for each in-network, Medicare-covered outpatient hospital facility visit. You have been asked to pay a $250 copayment for wound debridement. Wound debridement falls within the "Outpatient surgery including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 wound debridement provided on November 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete maxillary denture.

You asked the Plan to pre-approve the complete maxillary denture. You say that you would like the denture to be approved. The Plan denied your request. The Plan says this service is allowed one time every 60 months. The Plan also says that you received a maxillary denture less than 60 months ago.

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, dentures are limited to one set every 5 years. The record shows that you received a complete maxillary denture, and your maxillary denture benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture.