Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay for the periodic oral evaluation, bitewings, and prophylaxis. We decided that the Plan does not have to pay for the first intraoral periapical x-ray.
You asked the Plan to pay for the periodic oral evaluation, bitewings, and prophylaxis. You say that you thought checkups and cleanings were covered regardless of exhausting your $1,000 annual benefit limit. The Plan says that the annual maximum benefit limit has been reached.
We decided that the Plan has to pay for the periodic oral evaluation, bitewings, and prophylaxis.
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 must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan denied these services stating your annual maximum benefit limit has been reached. The Plan did not provide documentation supporting that your $1,000 annual maximum benefit for dental services has been exhausted. Based on this information, we decided that the Plan's rules for coverage of the periodic oral evaluation, bitewings, and prophylaxis have been met. Therefore, we decided that the Plan has to pay for the periodic oral evaluation, bitewings, and prophylaxis.
We also decided that the Plan does not have to pay for the first intraoral periapical x-ray.
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, first intraoral periapical x-ray is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray.
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 pay for a limited oral evaluation - problem focused (D0140), provided on February 22, 2021.
You asked the Plan to pay for a limited oral evaluation. You say that the service should be covered. The Plan denied your request. The Plan says it 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. Specifically, the service obtained is not listed in the Plan's 2021 EOC, and therefore, is not a covered benefit. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation - problem focused (D0140), provided on February 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the oxygen equipment (K0738, E1390) provided January 17, 2021.
You asked the Plan to waive the coinsurance for the oxygen equipment. You say that you believed that this would be completely covered. The Plan denied your request. The Plan says the coinsurance has processed correctly in this case.
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 20% coinsurance for durable medical equipment and related supplies. You have been asked to pay a total cost share of $28.33 for the oxygen equipment ($141.66 Medicare allowed amount x 20% coinsurance). This service falls within the durable medical equipment and related supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.
Therefore, we decided that the Plan does not have to waive the coinsurance for the oxygen equipment (K0738, E1390) provided January 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (11606, 14021) provided on November 3, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services cannot be verified.
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 11606 is "Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter over 4.0 cm". The CPT Code Manual definition of code 14021 is "Adjacent tissue transfer or rearrangement, scalp, arms and/or legs; defect 10.1 sq cm to 30.0 sq cm."

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 use of CPT code 11606 and 14021 is not supported by the records provided. Our coding reviewer found that the procedure report documents a less than 4cm diameter excision, therefore, CPT code 11606 is not supported. The documentation does not support an adjacent tissue transfer, without a secondary defect created, and therefore, CPT code 14021 is not supported by the documentation.

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 not been met. Therefore, we decided that the Plan does not have to pay for the services (11606, 14021) provided on November 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for comprehensive oral evaluation (D0150) and complete series of radiographic images (D0210), provided on December 22, 2020.

You asked the Plan to pay for oral evaluation and complete series. You say that the services should be covered. The Plan denied your request. The Plan says you have exceeded your Plan's maximum 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. Specifically, you have exceeded the Plan's allowed maximum benefit, and therefore, the services are not covered. Therefore, we decided that the Plan does not have to pay for comprehensive oral evaluation (D0150) and complete series of radiographic images (D0210), provided on December 22, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for initial hospital care (99222), provided on May 20, 2020.
You asked the Plan to waive the deductible for initial hospital care. You say that the service should be covered. The Plan denied your request. The Plan says the cost share was applied 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 your deductible is $500. This is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible for your Plan. This cost sharing is a contractual obligation that had not been met at the time the initial hospital care was received on May 20, 2020. The Plan allowed maximum for this benefit is $164.03, which was correctly applied towards your deductible, making this the amount you are responsible for.
Therefore, we decided that the Plan does not have to waive the deductible for initial hospital care (99222), provided on May 20, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the charges for the monthly oxygen rental fees for dates of
service February 14, 2021, and March 15, 2021.
You asked the Plan to waive the charges for the monthly oxygen rental fees. You say that you received this
oxygen concentrator starting in January 2018 and have made a total of 36 payments for it. You state that you
understood that Medicare allows a total of 36 payments then you should not owe additional charges. The Plan
denied your request. The Plan says your contract indicates that you must pay 20% coinsurance for durable
medical equipment. This was correctly applied to these claims.
Medicare rules require Plans to provide access to durable medical equipment (DME) that is covered by
Original Medicare. However, the rules do not require a Plan to pay for DME in the same manner as Original
Medicare.
Although Original Medicare requires 36 oxygen rental payments after which no payments are owed, your Plan contract says that your cost-sharing for oxygen does not change after 36 months. As such, the Plan has correctly processed the claims for oxygen rental. Therefore, we decided that the Plan does not have to waive the charges for the monthly oxygen rental fees for dates of service February 14, 2021, and March 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a 2D oral/facial photographic image (D0350) and a topical application (D1206), provided on January 19, 2021.
You asked the Plan to pay for a 2D oral/facial photographic image and a topical application. You say that the services should be covered. The Plan denied your request. The Plan says the services are non-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. Specifically, the services provided are not on the Plan's list of dental benefits, and therefore, are not covered. Therefore, we decided that the Plan does not have to pay for a 2D oral/facial photographic image (D0350) and a topical application (D1206), provided on January 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services rendered on September 11, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 99152 is not supported.
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 99152 is Moderate sedation services by other qualified health care professional requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status, patient 5 years of age or older, first 15 minutes.
We find that CPT code 99152 is not supported in the medical record. Specifically, there is no documentation of an independent trained observer to assist in monitoring the patient's level of consciousness and physiological status. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the moderate sedation services rendered on September 11, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the cervical spine.
You asked the Plan to pre-approve the MRI of the cervical spine. You say that it is felt this is needed to assess for injury related to the recent fall. The Plan denied your request. The Plan says further imaging can only be approved when additional tests are needed to direct your care. The appeal documents did not mention why more studies in clinically necessary at this time.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the MRI of the cervical spine. Our reviewer says that the requested imaging is not considered medically reasonable and necessary at this time. Our physician reviewer found the enrollee previously underwent a C4 corpectomy with a decompression and fusion at C5-6. The enrollee recently had a fall and complains of left arm radicular pain to fingers. Neurologic examination did not reveal deficits. The x-rays did not reveal acute injury, and hardware appeared stable. The enrollee was administered a Medrol dose pack and scheduled for return visit after a requested CT scan and MRI. The medical record does not indicate that a new finding is present. The medical record indicates the enrollee is receiving treatment and will be reassessed following that treatment. The medical record does not support the medical necessity or reasonableness, as defined by Medicare rules, for the requested MRI at this time.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the MRI of the cervical spine have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the cervical spine.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visit with an out-of-network urologist.

You asked the Plan to pre-approve the out-of-network office visit. You say that you were told you couldn't get an appointment with your previous urologist. You say that you assumed it was fine to see a different urologist and didn't know it would require a referral. The Plan denied your request. The Plan says in-network providers are available.

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 office visit with an out-of-network urologist.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF services.

You asked the Plan to pre-approve the SNF services. The Plan denied your request. The Plan says SNF services are not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 the SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that from a nursing perspective, the enrollee received oral medications and insulin. The enrollee had stable vital signs. She was treated for pain with effect and her lungs were clear. Regarding rehabilitation services, the enrollee received physical therapy (PT) and occupational therapy (OT) in the SNF. By the dates in question, the enrollee was at a stand by assist to supervision level with functional mobility including gait to 250 feet x 2 with a rolling walker. The enrollee required varying assist with activities of daily living. There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. As a practical matter, this enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.

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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on February 14, 2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
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 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 physician services provided to the enrollee on February 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Group 3 power wheelchair push handles, light kit or
electronic connection.
You asked the Plan to pre-approve push handles (K0108), light kit (K0108), and electronic connection
(E2310). You say that the enrollee needs a replacement Group 3 power wheelchair and accessories. The Plan
denied your request. The Plan says the electronic connection is not medically needed as there is no need to
control the power options through the joystick. The push handles and light kit do not serve a medical purpose.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
The light kit and push handles do not serve a purpose that is primarily medical in nature. These items are
available to the general public and would be helpful even to those who are not sick or injured. The record
shows upper limb strength and function are adequate for the enrollee to control the power options using their
own switches which are included in the allowance of the power options.
Therefore, we decided that the Plan does not have to pre-approve a replacement Group 3 power wheelchair
push handles, light kit or electronic connection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the home ventilator, any type, used with non-invasive interface (E0466).
You asked the Plan to pre-approve the ventilator. You say that the medical records provided support the necessity of the service in dispute. The Plan denied your request. The Plan says the documentation does not support the medical necessity for the request for this non-invasive ventilator.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 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 ventilator. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this enrollee has very severe COPD and may benefit from PAP support at night. He has had a Trilogy ventilator for some time. However, the medical records show he is unable to use it enough to be beneficial, or to meet minimum Medicare requirements.
His usage of the device in late 2020 showed the device was used for at least 4 hours on only 6.7% of days. Furthermore, BiPAP can provide the AVAPS mode of support that has been ordered for the ventilator, at much less cost. Medicare does not cover a ventilator when used as BiPAP. A home ventilator is considered not 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 the ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve the home ventilator, any type, used with non-invasive interface (E0466).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a consultation and a root canal to be performed by an
endodontist.
You asked the Plan to pay for the consultation and root canal. You say that you would like these services
approved for coverage because you are in a lot of pain. The Plan denied your request. The Plan says there is no
benefit for a root canal, or for services to be performed by an endodontist.
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
covered when they are received by anyone other than a participating general dentist. Therefore, we decided that
the Plan does not have to pay for a consultation and a root canal to be performed by an endodontist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a comprehensive orthodontic treatment of adult
dentition (D8090).

You asked the Plan to pre-approve the dental service. You say that this is medically necessary. You say that
you keep losing weight and sleep and are in extreme pain. You say that you need medical help to align your
jaw. The Plan denied your request. The Plan says comprehensive orthodontic treatment of adult dentition is not
listed as a covered service.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a
comprehensive orthodontic treatment of adult dentition (D8090).