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

We decided that the Plan does not have to pre-approve a Group 3 standard power wheelchair (K0861) with 
features including a power seating system (E1007). 
 
You asked the Plan to pre-approve a Group 3 power wheelchair with features including power seating. You say 
that the requested item is a medical necessity for the enrollee. The Plan denied your request. The Plan says 
rules for coverage have not been met because the requested item is not medically necessary. 
 
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 Group 3 power wheelchair with 
features including power seating. Our reviewer says that the requested items are not considered medically 
reasonable and necessary in this case. Our physician reviewer found that, based on the medical records 
provided, there is documentation that the enrollee has a covered indication that would require a Group 3 power 
wheelchair as specified in Medicare rules. However, there is no documentation that the enrollee satisfies the 
basic requirements as listed in the rules for a power seating system. There is no documentation that the enrollee 
has a high risk for development of a pressure ulcer and is unable to perform a functional weight shift; or that 
the enrollee utilizes intermittent catheterization for bladder management and is unable to independently transfer 
from the wheelchair to bed; or that the power seating system is needed to manage increased tone or spasticity. 
The rules for the requested power wheelchair mandate that the enrollee must meet coverage criteria for a power 
tilt and recline seating system but the enrollee does not meet the criteria; therefore, the requested power 
wheelchair is not medically necessary and reasonable. 
 
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 with features including power seating have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 standard power 
wheelchair (K0861) with features including a power seating system (E1007).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a posterior interspinous decompression spacer procedure.
You asked the Plan to pre-approve interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869). You say that the minimally invasive procedure is the most appropriate treatment for this enrollee. The Plan denied your request. The Plan says there are not enough studies on the device to show it is safe and effective.
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 interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the interlaminar spacer device is experimental. More research is needed to show safety and efficacy of the device.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of interlaminar/interspinous process stabilization/distraction device, without open
decompression or fusion, including image guidance when performed, lumbar; single level (22869) have not
been met. Therefore, we decided that the Plan does not have to pre-approve a posterior interspinous
decompression spacer procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), and a teeth cleaning (D1110) provided on January 29, 2021.
You asked the Plan to pay for a periodic oral evaluation, and a teeth cleaning. You say that you were told the provider was in-network. The Plan denied your request. The Plan says you are not covered for these services when seen by an out-of-network provider.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this case. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a periodic oral evaluation, and a teeth cleaning have not been met. Specifically, services were provided by an out-of-network provider without prior authorization. The Plan has contracted providers available to provide these services. 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 a periodic oral evaluation (D0120), and a teeth cleaning (D1110) provided on January 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the crutch substitute (CPT code E0118) purchased on February 8, 2021, from an out-of-network provider.
You asked the Plan to pay for the DME. You say that this should be covered because you were unaware that you had to find a contracting DME supplier. The Plan denied your request. The Plan says this provider is not in your network.
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 had network providers available who could have provided 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 crutch substitute
(CPT code E0118) purchased on February 8, 2021, from an out-of-network provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit provided on March 11, 2021 by an OON provider.
You asked the Plan to pay for the domiciliary or rest home visit. You say that the treatment provided was medically necessary. The Plan denied your request. The Plan says the treatment was rendered by an OON provider. The Plan also says that prior authorization was not obtained.
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 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 domiciliary or rest home visit provided on March 11, 2021 by an OON provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection procedure for contrast knee arthrography or contrast enhanced CT/MRI knee arthrography represented by code 27369 provided on January 19, 2021.
You asked the Plan to pay for code 27369. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code is Injection procedure for contrast knee arthrography or
contrast enhanced CT/MRI knee arthrography.
We find that CPT code is not supported in the medical record. Specifically, the medical record provided does
not show that an injection procedure for contrast knee arthrography or contrast enhanced CT/MRI knee
arthrography was performed. Based on this information, we decided that Medicare rules for coverage of code
27369 have not been met. Therefore, we decided that the Plan does not have to pay for the injection procedure
for contrast knee arthrography or contrast enhanced CT/MRI knee arthrography represented by code 27369
provided on January 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composites (D2330 and D2391) provided on April 1, 2021.
You asked the Plan to pay for the resin-based composites (D2330 and D2391). You say that this work was to prevent decay. You say that you were told this was covered with a $95 copayment per tooth. 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 resin-based composites (D2330 and D2391) provided on April 1, 2021
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the muscle skin graft services provided on October 6, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the muscle skin graft services. You say that you feel this claim should be paid. The Plan denied your request. The Plan says the services were processed correctly per the enrollee's plan 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 had network providers
available who could have provided 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 muscle skin graft services provided on October
6, 2020 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited oral evaluation (D0140 x2), an intraoral periapical radiographic image (D0220 x2), a pulp vitality test (D0460 x2), endodontic therapy (D3310 x2, D3320 x2), canal preparation and fitting of pre-formed dowel or post (D3950 x4) provided from June 17, 2020, through June 24, 2020.
You asked the Plan to pay for a limited oral evaluation, an intraoral periapical radiographic image, a pulp vitality test, endodontic therapy, canal preparation and fitting of pre-formed dowel or post. You say that because of cancer treatments, you suffered severe damage to the remaining teeth. The Plan denied your request. The Plan says the services at issue are not covered benefits.
Medicare generally does not cover dental services. The Plan follows the same rule.
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid
for by Medicare. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140
x2), an intraoral periapical radiographic image (D0220 x2), a pulp vitality test (D0460 x2), endodontic therapy
(D3310 x2, D3320 x2), canal preparation and fitting of pre-formed dowel or post (D3950 x4) provided from
June 17, 2020, through June 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on March 25, 2021.
You asked the Plan to pay for the dental service. You say that this was for a regular evaluation. You say that the provider billed for a codes that is not covered. You say that you tried to have the provider change the code, but they refused to. You also say that you would like this bill to be paid for. The Plan denied your request. The Plan says limited oral evaluation is not listed as a covered service. The Plan also says that you signed a pay agreement verifying that you understand that you are financially responsible for all charges whether or not paid by insurance.
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 limited oral evaluation (D0140) provided on March 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on December 16, 2019 by an out-of-network (OON) provider.
You asked the Plan to pay for the OON services. You say that you were unaware that an authorization was required. The Plan denied your request. The Plan says there are plan providers available for this 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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the services at issue in this appeal. 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 the office visit provided on December 16, 2019 by an out-of-network (OON)
provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power-tilt seating system (E1002) and additional accessories (E0955, E1028, E2310, E2361, and E2603).
You asked the Plan to pre-approve a group 2 power wheelchair (K0836) and accessories. You say that the power wheelchair and accessories requested are medically necessary for the enrollee. The Plan says that while the requested power wheelchair and Medicare approved accessories were approved, the enrollee does not meet criteria for the requested power-tilt seating system (E1002) and additional accessories (E0955, E1028, E2310, E2361, and E2603).
The Plan must follow Medicare rules. Medicare has specific coverage criteria for power wheelchair accessories. 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 power-tilt seating system (E1002) and additional accessories (E0955, E1028, E2310, E2361, and E2603). Our reviewer says that there is no documentation that the enrollee meets the LCD criteria for the requested E1002 (power seat tilt). Medical records do not document a history of skin ulceration and inability to perform a functional weight shift. There is no documentation that the enrollee meets the LCD criteria for the requested E0955 (cushioned headrest). There is no documentation that the enrollee meets the LCD criteria for the requested E1028x2 (wheelchair manual swing away and removable headrest hardware). There is no documentation that the enrollee meets the LCD criteria for the requested E2361. Therefore, Medicare criteria for those accessories are not met. 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 requested accessories are not met. Therefore, we decided that the Plan does not have to pre-approve a power-tilt seating system (E1002) and additional accessories (E0955, E1028, E2310, E2361, and E2603).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for massage therapy provided by an out-of-network provider on 
October 16, 2020. 
 
You asked the Plan to pay for massage therapy. You say that it is expensive to pay for massage therapy. You 
say that you would not have gone to the visit if you knew it would not be covered. The Plan denied your 
request. The Plan says prior authorization is required for any services provided by a non-contract provider. 
 
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 had network providers 
available who could have provided 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 massage therapy provided by an out-of-network 
provider on October 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the pneumatic compression device (E0676) provided May 22, 2020.
You asked the Plan to pay for a pneumatic compression device. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan.
This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pay for the pneumatic compression device (E0676) provided May 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a capsule endoscopy.
You asked the Plan to pre-approve gastrointestinal tract imaging, intraluminal (eg, capsule endoscopy),
esophagus through ileum, with interpretation and report (91110). You say that the enrollee needs a capsule
endoscopy because of abnormal weight loss. The Plan denied your request. The Plan says the enrollee's
extensive testing has been inconclusive and there is lack of covered indications noted in the LCD.
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 gastrointestinal tract imaging,
intraluminal (eg, capsule endoscopy), esophagus through ileum, with interpretation and report (91110). Our
reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our
physician reviewer found the CT scan offered no objective evidence of small bowel pathology, although
Duplex testing supported a suspicion in September 2020 of mesenteric ischemia. Ischemic gut however has not
been confirmed endoscopically. The enrollee's available record does not support that provided LCD L38826
criteria are met for the service under review.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of gastrointestinal tract imaging, intraluminal (eg, capsule endoscopy), esophagus
through ileum, with interpretation and report (91110) have not been met. Therefore, we decided that the Plan
does not have to pre-approve a capsule endoscopy.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for psychiatric services (90791, 90834)
provided by an out-of-network (OON) provider from November 25, 2020, to December 30, 2020.
You asked the Plan to waive the deductible for psychiatric services. You say that you were not aware there was
a deductible for out-of-network services. The Plan denied your request. The Plan says these services processed
correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that there is a $500 deductible for out-of-network services that are not urgent,
emergent, or supplemental.
The services you asked the Plan to waive the deductible for was provided by an out-of-network provider and
were not urgent, emergent, or supplemental. The Plan has followed Medicare rules by clearly disclosing in the
contract that there is a $500 deductible for out-of-network services that are not urgent, emergent, or
supplemental. This cost sharing is a contractual obligation that had not been met at the time psychiatric services
was received on November 25, 2020 to December 30, 2020. Therefore, we decided that the Plan does not have
to waive the deductible for psychiatric services (90791, 90834) provided by an out-of-network (OON) provider
from November 25, 2020, to December 30, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from March 2, 2021, through March 8, 2021.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you were told you would not have to pay for these charges. The Plan denied your request. The Plan says the copayment was 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $200 copayment per day from days 1 to 6. Your inpatient cost share will begin on day one each time you are admitted for inpatient hospital care. The enrollee has been asked to pay a $200 copayment per day from days 1 to 6. The services at issue fall within the inpatient hospital care benefit category. 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 copayment for inpatient hospital care from March 2, 2021, through March 8, 2021.