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

We decided that the Plan does not have to pre-approve a maxillary partial denture (D5225).
You asked the Plan to pre-approve the maxillary partial denture. The Plan denied your request. The Plan says this service is not a covered 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 pre-approve a maxillary partial denture (D5225).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve platelet-rich plasma injection (CPT 0232T).
You asked the Plan to pre-approve the injection. You say that this is needed for right knee pain. The Plan
denied your request. The Plan says this is considered investigational for all orthopedic reasons.
The Plan must follow Medicare rules. Medicare rules say that CPT 0232T is not a covered code.
The requested injection is coded with CPT 0232T. Based on this information, we decided that Medicare rules
for coverage of the injection have not been met. Therefore, we decided that the Plan does not have to preapprove
platelet-rich plasma injection (CPT 0232T).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power mobility device with accessories (E1028, K0848, K0108).
You asked the Plan to pre-approve the power chair and accessories. You say that the chair 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 a Group 3 power wheelchair can be covered only for enrollees who have a mobility limitation that is due to: 1. A neurological condition; 2. Myopathy; or 3. Congenital skeletal deformity. The file does not show that the enrollee has a mobility limitation that is due to a neurological condition, myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a group 3 power mobility device with accessories (E1028, K0848, K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for catheter and supplies provided to the enrollee from January 21, 2020 through April 13, 2020.
You asked the Plan to waive the coinsurance for the supplies. You say that you are appealing the member's cost-share responsibility for the services the member received. The Plan denied your request. The Plan says the claims were processed accordingly with the member's 2020 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that the enrollee received catheter and supplies from January 21, 2020 through April 13, 2020. The enrollee's EOC states, "prosthetic devices and related supplies are covered with a 20% coinsurance. Devices (other than dental) that replace all or part of a body part or function. These include, but are not limited to: colostomy bags and supplies directly related to colostomy care, pacemakers, braces, prosthetic shoes, artificial limbs, and breast prostheses (including a surgical brassiere after a mastectomy). Includes certain supplies related to prosthetic devices, and repair and/or replacement of prosthetic devices." Therefore, the enrollee is asked to pay 20% coinsurance for the supplies. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan.
Therefore, we decided that the Plan does not have to waive the coinsurance for catheter and supplies provided to the enrollee from January 21, 2020 through April 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies and ointment.
You asked the Plan to pre-approve incontinence supplies (A4335) and ointment (A6250). You say that the
enrollee needs the supplies to prevent skin irritation and infection. The Plan denied your request. The Plan says
these items are not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered
because they are hygienic items that are non-reusable.
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of
these items. The requested supplies are non-reusable disposable supplies not covered by Medicare. Therefore,
we decided that the Plan does not have to pre-approve incontinence supplies and ointment.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dual diagnostic medial branch blocks.
You asked the Plan to pre-approve diagnostic medial branch blocks. You say that the enrollee has tried and
failed medications along with physical therapy and needs this procedure. The Plan denied your request. The
Plan says the denial of authorization for these services is correct, because the Plan has already approved 2
injections and Medicare only allows 2 joints to be injected per session in each region.
The Plan must follow Medicare rules. Medicare rules say that for diagnostic medial branch blocks, a maximum
of 2 joints is allowable per session per region.
We looked at the file and Medicare rules. The Plan has already approved 2 injections, therefore the additional 2
injections requested would exceed the frequency limit according to Medicare rules. Based on this information,
we decided that Medicare rules for coverage of diagnostic medial branch blocks have not been met. Therefore,
we decided that the Plan does not have to pre-approve dual diagnostic medial branch blocks.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean immediate mandibular partial denture, immediate maxillary partial denture, four periodontal scalings and root planings, and 7 extractions.You asked the Plan to pre-approvethe immediate dentures, scalings and planings, and extractions. You say that the dentures are intended to last up to five years, and not 2 to 3 months like the current dentures you have. You also say that the extractions are medically necessary.The Plan denied your request. The Plan says immediate mandibular partial denture, immediate maxillary partial denture, and periodontal scaling and root planing are not covered under your plan. The Plan also says that your extractions benefit has been exhausted for the 2020 plan year.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, immediate mandibular partial denture, immediate maxillary partial denture, and periodontal scaling and root planing are not among those covered under this benefit. The contract also clearly states extractions are limited to two procedures per calendar year. The records show that you received approval for 2 extractions on May 11, 2020, valid until August 9, 2020, and your extractions benefit has been exhausted.Therefore, wedecided that the Plan does not have to pre-approvean immediate mandibular partial denture, immediate maxillary partial denture, four periodontal scalings and root planings, and 7 extractions.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an emergency alert system.
You asked the Plan to pre-approve an emergency alert system. You say that you need an emergency alert system. The Plan denied your request. The Plan says an emergency alert system is not covered by Medicare or the Plan.
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. A life alert system is an emergency communications system which does not serve a diagnostic or therapeutic purpose and is excluded from coverage by Medicare. Therefore, we decided that the Plan does not have to pre-approve an emergency alert system.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a peripheral nerve block.
You asked the Plan to pre-approve peripheral nerve block (64450). You say that the enrollee needs this nerve block for low back pain. The Plan denied your request. The Plan says there is not enough medical evidence to show the procedure is helpful.
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 peripheral nerve block (64450). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this nerve block would be considered experimental/ investigational for this problem. There are other evidence based alternatives available. This procedure is not medically reasonable or 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 peripheral nerve block (64450) have not been met. Therefore, we decided that the Plan does not have to pre-approve a peripheral nerve block.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from December 31,
2019 through January 28, 2020.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you are appealing your
cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim
was processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance).
Review of the file shows that you received inpatient hospital care from December 31, 2019 to January 28,
2020. If the plan applied $265.00 to 8 days of inpatient hospital care then the copayment would be $2,120.00.
However, you only needed to pay $1,261.00 in order to meet your $2,900.00 out-of-pocket maximum. The plan
applied a $1261.00 copayment to this claim. The copayment was correctly applied. 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 inpatient hospital care from December 31, 2019 through January 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the one additional intraoral periapical x-ray and 2D oral/facial photographic image provided on February 28, 2020.
You asked the Plan to pay for the one additional intraoral periapical x-ray and 2D oral/facial photographic image. You say that you were told that this provider accepts Medicare and your insurance plan. You also say that the office would give you a discount for all services even though you do not have a separate dental plan. The Plan denied your request. The Plan says 2D oral/facial photographic image is not a covered benefit. The Plan also says that your plan does not cover more than one set of intraoral x-rays per calendar year.
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 2D oral/facial photographic image is not among those covered under this benefit. The contract also clearly states that intraoral x-rays are limited to one procedure per calendar year. The record shows that you received two additional intraoral periapical x-rays on February 28, 2020, one of which was covered, and your intraoral x-rays benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the one additional intraoral periapical x-ray and 2D oral/facial photographic image provided on February 28, 2020.
Your complaint about your issues with this dental provider 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the automatic external defibrillator (AED) provided on January 22, 2020.
You asked the Plan to pay for the automatic external defibrillator (K0606). You say that the AED was medically necessary. The Plan denied your request. The Plan says the enrollee was inpatient therefore separate payment cannot be made.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a hospital to be a home. Records show that the automatic external defibrillator (K0606) was used in a hospital. Therefore, we decided that the Plan does not have to pay for the automatic external defibrillator (AED) provided on January 22, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for a blood test (82565), bone imaging (78306) and a Computed Tomography (CT) scan of the abdomen and pelvis (74178) provided March 9, 2020.
You asked the Plan to waive the copayments for the blood test, bone imaging, and CT scan. You say that the copayments should be waived as these services were always covered in the past. The Plan denied your request. The Plan says the correct copayments were applied.
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 $10 copayment for Lab Services, a $10 copayment for diagnostic tests and a $100 copayment for Advanced Imaging Services. You have been asked to pay a $9.18 copayment for a blood test, a $10 copayment for bone imaging and a $100 copayment for a CT scan. The blood test falls within the lab services benefit category. The bone imaging falls within the diagnostic tests benefit category, and the CT scan is within the Advanced Imaging Category. In the case of the blood test, the allowable amount of $9.18 is less than the $10 copayment listed in the plan contract, so the lesser amount was charged. 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 a blood test (82565), bone imaging (78306) and a Computed Tomography (CT) scan of the abdomen and pelvis (74178) provided March 9, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for arthrocentesis injection services (CPT 20611 and HCPCS J3304)
provided to the enrollee on December 3, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says that since these codes were already paid on the originally submitted claim, and are not supported
as being performed twice, they are not appropriate for additional reimbursement.
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 the denied codes is:
HCPCS J3304:
Injection, triamcinolone acetonide, preservative-free, extended-release, microsphere formulation, 1 mg
CPT 20611:
Arthrocentesis, aspiration and/or injection
We asked our coding 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 the services. Our reviewer says that the
services at issue in this case were supported by the medical records. Our physician reviewer found the
documentation reviewed was two procedure reports with different dates of service. Both were injections of
bilateral knees. There is no documentation showing that both procedures were paid.
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 services have been met. Therefore, we decided that the Plan has to pay for
arthrocentesis injection services (CPT 20611 and HCPCS J3304) provided to the enrollee on December 3,
2019.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary partial denture (D5211).
You asked the Plan to pre-approve the maxillary partial denture. You say that your denture was accidentally
thrown away. You also say that you need this denture because it replaces your upper front tooth and you do not
want to have a negative appearance. The Plan denied your request. The Plan says this service exceeds the
maximum count allowed per period.
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, maxillary partial denture (D5211) is
limited to one procedure every five plan years. The record shows that you received a maxillary partial denture
(D5211) on August 28, 2019 and your maxillary partial denture (D5211) benefit has been exhausted.
Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture (D5211).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve extraction, erupted tooth requiring removal of bone
and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated for tooth #27 (D7210),
for the enrollee.
You asked the Plan to pre-approve the dental services. You say that you are requesting review of denial of
services. The Plan denied your request. The Plan says the enrollee exhausted their benefit frequency limit.
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 enrollee exhausted their benefit frequency limit, because this same service has been provided for tooth #27
on March 9, 2017. The enrollee's benefits states, "extraction, erupted tooth requiring removal of bone and/or
sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210): is covered for one (1)
tooth/lifetime." Therefore, we decided that the Plan does not have to pre-approve extraction, erupted tooth
requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if
indicated for tooth #27 (D7210), for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee on December 27, 2019.
You asked the Plan to pay for the services. You say that the services are medically necessary. The Plan denied
your request. The Plan says the enrollee does not have out-of-network benefits.
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 services provided to the enrollee on December
27, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing provided on July 17, 2019.You asked the Plan to pay for the drug testing. You say that the codes are supported by the physicians custom profile.The Plan denied your request. The Plan says the order does not indicate the specific laboratory billed tests.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 G0481 is definitive drug testing of 8-14 drug classes. We find that CPT code G0481 is not supported in the medical record. There were insufficient records that show the tests were needed to identify specific substances that were inadequately detected by a presumptive drug test. There is no evidence that shows the test was individualized to identify specific non-prescribed medications or illicit substances. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the definitive drug testing provided on July 17, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe pin retention, panoramic x-ray, and resin-based composite provided on February 13, 2020.You asked the Plan to pay forthe pin retention, panoramic x-ray, and resin-based composite. You say that you do not feel you should be responsible for paying more when you pay $20.00 extra every month for extra dentalwork.The Plan denied your request. The Plan says pin retention is not covered, and you are responsible for the full amount of this charge. The Plan also says that in-network, you must pay a 30% coinsurance for each covered diagnostic x-ray and restorative service per calendar year.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, pin retention is not among those covered under this benefit. The contract also clearly states that you are responsible for a 30% coinsurance for both diagnostic x-rays and restorative services that are provided in-network.Therefore, we decided that the Plan does not have to pay forthe pin retention, panoramic x-ray, and resin-based composite provided on February 13, 2020.