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

We decided that the Plan does not have to reimburse you for the 7 surgical extractions (D7140) provided on
June 18, 2019 by the oral surgeon.
You asked the Plan to reimburse you for the dental services. You say that you paid upfront for the extractions
because you had been advised by another office that your plan did not cover them. You say that in September
2019 a Plan representative advised that extractions were covered. You also say that the Plan advised you
needed your dentist to fax a referral for the oral surgeon. The Plan denied your request. The Plan says a referral
was not received for the services that were rendered to you by the provider in this case.
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 extractions are a covered service,
there was no referral for the provider in this case. The record shows that a referral was provided to the Plan, but
it was for a different oral surgeon and location. Therefore, we decided that the Plan does not have to reimburse
you for the 7 surgical extractions (D7140) provided on June 18, 2019 by the oral surgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation, first intraoral periapical x-ray, additional intraoral periapical x-ray, bitewings, panoramic x-ray, prophylaxis, and two resin-based composites provided on November 7, 2019.
You asked the Plan to pay for the dental services. You say that on the day of your dentist visit, no one told you that your Plan did not cover anything. The Plan denied your request. The Plan says these services are not covered under your 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 comprehensive oral evaluation, first intraoral periapical x-ray, additional intraoral periapical x-ray, bitewings, panoramic x-ray, prophylaxis, and two resin-based composites provided on November 7, 2019.
Your complaint about leaving the dentist office feeling worse than when you went to the dentist office 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the chest.
You asked the Plan to pre-approve a CT scan. You say that a CT scan is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of a CT scan.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a CT scan. Our reviewer says that a CT scan of the chest is not medically necessary at this time. Our physician reviewer found only a CT scan of the abdomen and pelvis are indicated for follow-up in this clinical circumstance. There are no other indications for an annual chest CT given. The service is not reasonable or 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 a CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the chest.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair (E0240).
You asked the Plan to pre-approve a shower chair. You say that you are requesting reconsideration of the Plan's denial. The Plan denied your request. The Plan says a shower chair is not a covered benefit under your contractual policy.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair (E0240).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray, elbow x-ray, computed tomography (CT) of the cervical spine, the head or brain CT, the pelvis CT, and the shoulder x-ray provided on February 20, 2019.
You asked the Plan to pay for the radiology services. You say that the services that were provided to the enrollee were not related to their hospice diagnosis. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked.
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 chest x-ray, elbow x-ray, computed tomography (CT) of the cervical spine, the head or brain CT, the pelvis CT, and the shoulder x-ray provided on February 20, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a wrist-hand orthosis (L3916) provided to the enrollee on
April 25, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your
request. The Plan says the documentation does not indicate services are necessary for treatment of the
enrollee's condition.
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 wrist-hand orthosis
(L3916) provided to the enrollee on April 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on October 17, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 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 physician's services provided on October 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the home ventilator to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the home ventilator. You say that you believe that the Plan's disease management program is better suited for the enrollee than that of the in-network provider. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. There are in-network providers that is available to provide the 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 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the home ventilator to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse and additional $300 for the core build up (D2950), 2 crowns (D2740), and the drugs and medicaments (D9630) provided on July 15, 2019.
You asked the Plan to reimburse and additional $300 for the dental services. You say that your policy has a $1,700 allowance for dental services per year. You say that the reimbursement you received for the services on July 15, 2019 is about $300 short. The Plan denied your request. The Plan says the services that were not paid are not Medicare covered dental services. The Plan says that you have already been reimbursed the full amount of the dental allowance for non-Medicare covered dental services.
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, annual maximum has been exhausted. Therefore, we decided that the Plan does not have to reimburse and additional $300 for the core build up (D2950), 2 crowns (D2740), and the drugs and medicaments (D9630) provided on July 15, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a screening mammography (77067) and screening digital breast tomosynthesis (77063) provided on August 26, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the screening mammography and screening digital breast tomosynthesis. You say that you were not aware the provider was out-of-network. The Plan denied your request. The Plan says non-emergent services rendered by non-participating providers in non-participating facilities require prior authorization, therefore coverage criteria has not been met.
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 a screening mammography (77067) and screening digital breast tomosynthesis (77063) provided on August 26, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital care for spinal surgery.
You asked the Plan to pre-approve acute inpatient hospital care. You say that this service should be approved at
inpatient level of care. The Plan denied your request. The Plan says the surgery is approved but can be provided
in the outpatient setting.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.
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 acute inpatient hospital care. Our
reviewer says that acute inpatient hospital care is not medically necessary. Our physician reviewer found the
medical records do not support the need for inpatient level of care. 5 days of admission is not medically needed
after spinal fusion surgery.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the
Plan does not have to pre-approve acute inpatient hospital care for spinal surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for stem cell therapy provided on June 3, 2019.
You asked the Plan to pay for this treatment. You say that this treatment was medically necessary. The Plan
denied your request. The Plan says Medicare coverage criteria were not 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 pay for this treatment. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the complaint was for hip pain. The use of stem cell therapy for hip pain is considered experimental
and/or investigational. It is not medically necessary and reasonable to use stem cell therapy for hip pain. 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 treatment have not been met. Therefore, we decided that the Plan does not
have to pay for stem cell therapy provided on June 3, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan has to pre-approve CT scan of the chest. We decided that the Plan does not have to pre-approve CT scan of the neck.
You asked the Plan to pre-approve the CT scans. You say that this is medically necessary. The Plan says that this is not medically necessary.
We decided that the Plan has to pre-approve CT scan of the chest.
The Plan follows Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request for CT scan of the chest. Our reviewer says that the scan of the chest is medically reasonable and necessary. Our physician reviewer found that the enrollee has had extensive work-up including CT scans, PET/CT and endobronchial biopsy in the past which all have been abnormal and thus qualifies for CT of the chest. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CT scan of the chest have been met. Therefore, we decided that the Plan has to pre-approve CT scan of the chest.
We also decided that the Plan does not have to pre-approve CT scan of the neck.
The Plan follows Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request for the CT scan of the neck. Our reviewer says that the request is unclear and not medically reasonable or necessary. Our physician reviewer found that the records describe a request for CT of the neck which is not supported by the records with no clinical notes describing symptoms in the neck. That said, the appeal has included a request not for CT of the neck but CT of the sinuses. The request needs to be clarified. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CT scan of the neck have not been met. Therefore, we decided that the Plan does not have to pre-approve CT scan of the neck.
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 pre-approve continuous glucose monitor supplies represented by CPT codes A9276 and A9277.
You asked the Plan to pre-approve the continuous glucose monitor supplies. You say that the enrollee requires both basal and prandial insulin therapy and has been on insulin pump therapy for more than 15 years. You say that the enrollee has been using Medtronic Guardian continuous glucose monitoring and it has been extremely effective for him. You say that the enrollee's glycemic control will deteriorate and place him at high risk for vascular complicates of diabetes if he is not able to continue to use Medtronic CGM along with his insulin pump. The Plan denied your request. The Plan says the codes in dispute are never covered by Medicare.
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. Medicare rules say that codes A9276 and A9277 describe the supplies used with a non-therapeutic CGM. We looked at the file and Medicare rules. Medicare rules say that non-therapeutic CGMs are not covered. The supplies being requested are for use with a non-therapeutic CGM and are, therefore, also not covered. Therefore, we decided that the Plan does not have to pre-approve continuous glucose monitor supplies represented by CPT codes A9276 and A9277.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve wheelchair van transportation for the enrollee.
You asked the Plan to pre-approve these services. You say that the enrollee needs transportation to dialysis. The Plan denied your request. The Plan says wheelchair van transportation is not covered.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport services. The services you have asked the Plan to pre-approve are wheelchair van transport services. Therefore, we decided that the Plan does not have to pre-approve wheelchair van transportation for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health services.
You asked the Plan to pre-approve home health services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 home health services. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee currently ambulates with a walker and has severe kyphosis. Skilled nursing has been education regarding medications and medical issues. There are no documented complex skilled nursing needs such as injections, catheter management, complicated wound care or IV management. Based on available records, the enrollee does not meet criteria for coverage of home health nursing services. There are no documented complex skilled nursing needs. The records do not show that skilled nursing services are required to effectively provide treatment, care, and/or services which are medically necessary for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says you can be referred to available in-network providers.
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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral to an out-of-network provider.