Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea group 3 power wheelchair (K0861).You asked the Plan to pre-approvea group 3 power wheelchair. You say that this item is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for this item.The Plan follows 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; or3. Congenital skeletal deformity.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 group 3 power wheelchair. Our reviewer says that a group 3 power wheelchair is not medically necessary at this time. Our physician reviewer found while the patient has a mobility deficit that interferes with her mobility to perform MRADLS she does not have meet the criteria for a Group 3 Power Wheelchair. The patient does not have a diagnosis of neurological disease, myopathy or congenital skeletal deformity and therefore she does not meet Medicare criteria.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 group 3 power wheelchair have not been met. Therefore, wedecided that the Plan does not have to pre-approvea group 3 power wheelchair (K0861).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea lumbar epidural injection.You asked the Plan to pre-approvea lumbar epidural injection. You say that the requested lumbar epidural injection is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for therequested lumbar epidural injection.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 a lumbar epidural injection. Our reviewer says that the enrollee does not meet criteria for the requested lumbar epidural injection. Our physician reviewer found the enrollee is with back pain. Criteria for repeat injection have not been met. There is no documentation of more than 50% relief from previous injection.We looked at this physician's review, the file, and Medicare rules. Based on this information, wedecided that Medicare rules for coverage of a lumbar epidural injection have not been met.Therefore, we decided that the Plan does not have to pre-approvea lumbar epidural injection.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the mechanical traction therapy (97012) provided on  January 29, 2020. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of Plan's denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit under your contractual policy. 
 
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. However, the Plan offers a chiropractic benefit that exceeds Medicare coverage. 
 
Though the Plan offers a chiropractic benefit in excess of Medicare coverage, the service provided is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the mechanical traction therapy (97012) provided on January 29, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically
necessary. The Plan denied your request. The Plan says the requested IRF care is not considered medically
reasonable and necessary based on Medicare guidelines.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
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 IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the enrollee is status post stroke in 2018 with residual right hemiparesis. Now, the
member is neurologically stable and non-toxic. Strength on the right side is grossly 2 to 3 out of 5 per reports,
and the member is minimal/moderate assist for functional transfers as per recent therapy notes. There is
impaired Barthel scores, and balance is impaired. Safety risk is an issue.
Records do not indicate that there are significant, or complex medical/nursing issues that could not be
addressed at a lesser level of care. Ongoing pain medication and other medication management, skin care, and
daily therapy can be provided at a lesser level of care. In this case, the member is mostly minimal/moderate
assist for functional transfers and activities of daily living and a less intensive, longer duration of therapy will
allow for measurable gains to be attained within a reasonable, and predicted period. An IRF intensity is not
warranted.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the prefabricated post and core.
You asked the Plan to pre-approve the prefabricated post and core. You say that you are appealing the denial. The Plan denied your request. The Plan says the 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 the prefabricated post and core.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe MyoPro myoelectric orthosis (L8702).You asked the Plan to pre-approvethe orthosis. You say that given that traditional rehabilitation strategies have been tried and failed, the enrollee's care team has recommended him for myoelectric orthotic restoration.The Plan denied your request. The Plan says this item is considered experimental and investigational. There is insufficient evidence of its effectiveness in those with stroke and hemiparesis.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the orthosis have not been met.Therefore, we decided that the Plan does not have to pre-approvethe MyoPro myoelectric orthosis (L8702).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a Group 1 power mobility device. 
 
You asked the Plan to provide a Group 1 power mobility device. You say that the enrollee needs a Group 1 power mobility device. The Plan denied your request. The Plan says the enrollee is using a walker that meets the enrollee's mobility needs. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The assessment shows that the enrollee's condition can be improved by a walker. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to provide a Group 1 power mobility device.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay fortherapeutic exercises (97110x2) provided on February 3, 2020 through February 6, 2020.You asked the Plan to pay forthe therapeutic exercises. You say that you would like reconsideration because the services rendered were medically necessary.The Plan denied your request. The Plan says the documentation submitted does not support the service billedThe 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 97110 is therapeutic procedure, 1 or moreareas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility.We find that CPT code 97110 is not supported in the record. Specifically, 2 units of CPT code 97110 were billed for both February 3, 2020 and February 6, 2020. The record indicates that 10 minutes were spent rendering this procedure on the billed dates of service. The record does not support that 2 units of this service were rendered on each billed date of service. Based on this information, we decided that Medicare rules for coverage of the therapeutic exercises have not been met.Therefore, we decided that the Plan does not have to pay fortherapeutic exercises (97110x2) provided on February 3, 2020 through February 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forlimited exam to evaluate a problem (D0140) provided on March 16, 2020.You asked the Plan to pay forthe dental services. You say that you are appealing for reconsideration of the denied charges.The Plan denied your request. The Plan says you exhausted your 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.You exhausted your benefit frequency limit, because you had this same service performed on January 15, 2020. Your EOC states, limited exam to evaluate a problem (D0140) -one (1) procedure per plan year.Therefore, we decided that the Plan does not have to pay forlimited exam to evaluate a problem (D0140) provided on March 16, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation provided on April 6, 2020. 
 
You asked the Plan to pay for the problem focused limited oral evaluation. You say that the Plan should pay for this service because you needed an emergency tooth extraction. 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 your 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, preventive periodic oral dental exams are limited to twice per calendar year. The record shows that you received oral dental exams on January 7, 2020 and April 2, 2020 and your preventive periodic oral dental exams benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation provided on April 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral surgery (D7999) provided on March 16, 2020 and the consultation (D9310), bone graft (D7953) and tissue regeneration (D4266) provided on March 18, 2020.
You asked the Plan to pay for the oral surgery (D7999), consultation (D9310), bone graft (D7953) and tissue regeneration (D4266). You say that the extraction was necessary to deal with the infection. You say that you don't know what you would have done without the emergency care. The Plan denied your request. The Plan says the services are not covered benefits.
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 oral surgery (D7999) provided on March 16, 2020 and the consultation (D9310), bone graft (D7953) and tissue regeneration (D4266) provided on March 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve custom power wheelchair (K0861, E1028, E1007,
E2311, E2313, E2609. E2617) (no pa (E0956, E0955, E2363).
You asked the Plan to pre-approve the custom power wheelchair. You say that the records provided should
support the necessity of the service in dispute. The Plan denied your request. The Plan says the enrollee does
not meet the criteria for the requested power chair.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.
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 custom power wheelchair. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found it is not clearly documented in the provided medical records that the
enrollee has a personal mobility deficit that impairs participation in mobility related activities of daily living
that can only be managed with the use of a power mobility device. The records indicate he is walking 75 feet
with a wheeled walker. The records indicate he can safely operate the power mobility device that he is
currently using that is borrowed from the facility.
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 custom power wheelchair have not been met. Therefore, we decided that the
Plan does not have to pre-approve custom power wheelchair (K0861, E1028, E1007, E2311, E2313, E2609.
E2617) (no pa (E0956, E0955, E2363).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the DME provided on March 11, 2020.
You asked the Plan to waive the coinsurance for the DME. 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 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 you received the DME provided on March 11, 2020. You are asked to pay 20%
coinsurance for the DME. You are asked to pay 20% coinsurance for the DME. 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 the DME provided on March 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power mobility device repairs. 
 
You asked the Plan to pre-approve power mobility device tires and a battery. You say that you have had your power mobility device since 2010 and it needs tires and a battery. The Plan denied your request. The Plan says you do not meet criteria for a power wheelchair therefore, power wheelchair repairs are not covered. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file does not show that you have a mobility deficit that impairs your participation in MRADLs, or your condition cannot be improved by a walker, cane or manual wheelchair. This means that Medicare rules for coverage of a PMD have not been met. Since criteria is not met for a PMD the repairs are not covered. Therefore, we decided that the Plan does not have to pre-approve power mobility device repairs.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for2D oral/facial photographic image obtained intra-orally or extra-orally (D0350) provided on February 27, 2020 by an out-of-network provider.You asked the Plan to pay forthe dental services. You say that you are appealing for reconsideration of the denied charges.The Plan denied your request. The Plan says the service is not a covered benefit under the 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. This service is not listed in your EOC as a covered benefit; therefore, it is not covered.Therefore, we decided that the Plan does not have to pay for2D oral/facial photographic image obtained intra-orally or extra-orally (D0350) provided on February 27, 2020 by an out-of-network provider
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe prophylaxis and oral evaluation provided on April 20, 2020.You asked the Plan to pay forthe prophylaxis and oral evaluation. You say that this is your dentist. You say that the only other options are chain dentists.The Plandenied your request. The Plan says out-of-network dental services are 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 when received from an out-of-network provider. Therefore, we decided that the Plan does not have to pay forthe prophylaxis and oral evaluation provided on April 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for oral hygiene instructions (D1330), topical application of fluoride varnish (D1206), panoramic radiographic image (D0330), and oral/facial photographic images obtained intraorally or extraorally (D0350) provided on January 21, 2020 by an out-of-network provider. 
 
You asked the Plan to pay for the dental services. You say that you do not feel liable for the services. The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
The Plan states they approved the previously denied dental services; however the Plan will not covered the outof-network cost-share because your EOC states that you pay: 50% of billed charges up to the $1,000 allowance for covered dental services. You pay 100% of charges beyond your $1,000 allowance. Therefore, we decided that the Plan does not have to pay for oral hygiene instructions (D1330), topical application of fluoride varnish (D1206), panoramic radiographic image (D0330), and oral/facial photographic images obtained intraorally or extraorally (D0350) provided on January 21, 2020 by an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablations (RFA) to T5-T6, T6-T7 and T7- T8. 
 
You asked the Plan to pre-approve radiofrequency ablations. 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 follows Medicare rules. Medicare rules say that RFA is only covered for certain indications. 
 
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 radiofrequency ablations. Our reviewer says that the documentation does not support that the requested RFAs are medically reasonable or necessary. Our physician reviewer found the enrollee has chronic mid back pain. The enrollee has tried several medications without significant benefit. The enrollee underwent diagnostic thoracic Medial branch blocks and achieved 60% pain relief with the first set of injections and then 80% with the second set. The criteria for a positive diagnostic medical branch block is 80% pain relief for both diagnostic procedures. This was not achieved and therefore, the test should be interpreted as negative. Therefore, the enrollee does not meet criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of radiofrequency ablations have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablations (RFA) to T5-T6, T6-T7 and T7- T8.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed. 
 
You asked the Plan to pre-approve a semi-electric hospital bed (E0261). You say that the enrollee requires positioning of the body in ways not feasible with an ordinary bed. The Plan denied your request. The Plan says the documentation does not indicate the enrollee requires frequent and immediate need for a change in body position to qualify for a semi-electric hospital bed. 
 
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a semi-electric hospital bed (E0261) have not been met. Therefore, we decided that the Plan does not have to pre-approve a semi-electric hospital bed.