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

We decided that the Plan does not have to pre-approve the dentures to be attached to existing implants.
You asked the Plan to pre-approve the dentures. You say that the enrollee is losing weight because she has no teeth to chew. The Plan denied your request. The Plan says dentures are a non-covered service under Medicare without exception.
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 dentures to be attached to existing implants.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a manual wheelchair.
You asked the Plan to pre-approve a manual wheelchair. You say that this would assist in mobility. The Plan denied your request. The Plan says that you do not meet criteria for coverage.
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 manual wheelchair. Our reviewer says that a manual wheelchair is not considered medically reasonable and necessary in this case. You are walking with a rolling walker and therapy records indicate you are independent with mobility and transfers. The reports indicate you can ambulate in the home with the walker and the wheelchair is needed for mobility in the community. In addition, the provided medical records do not indicate that your home provides adequate access between rooms, maneuvering space, and surfaces for use of the manual wheelchair that is requested. Our physician reviewer found that your condition does not meet Medicare criteria for a manual wheelchair. 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 manual wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a manual wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for moderate sedation services (CPT 99152) provided to the enrollee on September 30, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says Current Procedural Terminology (CPT) 99152 remains 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 provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older." 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 the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found the enrollee underwent a cardiac catheterization with moderate sedation. The submitted procedure note does not note the presence of a second provider/observer. No documentation from a second provider/observer has been submitted for review. Therefore, the billing of CPT 99152, which requires the presence of an independent trained observer to monitor the sedation, is not supported. 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 services have not been met. Therefore, we decided that the Plan does not have to pay for moderate sedation services (CPT 99152) provided to the enrollee on September 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a kitchen renovation.
You asked the Plan to pre-approve home modifications. You say that it is medically necessary for the enrollee
to have an accessible kitchen. The Plan denied your request. The Plan says home renovations are not covered
by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Medicare does
not cover home modifications. Therefore, we decided that the Plan does not have to pre-approve a kitchen
renovation.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the shoulder surgery provided on January
23, 2020.
You asked the Plan to waive the cost share for the shoulder surgery. You say that you would like the $125
copayment waived because you paid your $750 deductible. The Plan denied your request. The Plan says you
have been charged the correct cost sharing amount.
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 $750 deductible that applies towards outpatient surgery and a $125
copayment after the deductible is met for each outpatient surgery and/or services at an ambulatory surgical
center or outpatient hospital facility.
The shoulder surgery you asked the Plan to waive the cost share for falls within the "Outpatient surgery,
including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category.
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible that
applies towards outpatient surgery and a $125 copayment after the deductible is met for each outpatient surgery
and/or services at an ambulatory surgical center or outpatient hospital facility. See chart below.
We decided that the Plan does not have to waive the cost share for the shoulder surgery provided on January
23, 2020.
You asked the Plan to waive the cost share for the shoulder surgery. You say that you would like the $125
copayment waived because you paid your $750 deductible. The Plan denied your request. The Plan says you
have been charged the correct cost sharing amount.
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 $750 deductible that applies towards outpatient surgery and a $125
copayment after the deductible is met for each outpatient surgery and/or services at an ambulatory surgical
center or outpatient hospital facility.
The shoulder surgery you asked the Plan to waive the cost share for falls within the "Outpatient surgery,
including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category.
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible that
applies towards outpatient surgery and a $125 copayment after the deductible is met for each outpatient surgery
and/or services at an ambulatory surgical center or outpatient hospital facility. See chart below.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the upper extremity prosthesis, custom glove (L7499) for artificial arm. 
 
You asked the Plan to pre-approve the custom glove. You say that the enrollee has a prosthetic arm and needs this glove as he is a very active man. Your clinician has written a letter explaining why this should be considered medically necessary. The Plan denied your request. The Plan says the requested glove is not covered as the supplier used incorrect coding. A custom glove 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 looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the custom glove have not been met. Therefore, we decided that the Plan does not have to preapprove the upper extremity prosthesis, custom glove (L7499) for artificial arm.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Intracept procedure.
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has low back pain. The requested Intracept procedure is considered experimental in nature, as more research is needed to show safety and efficacy. The services are therefore 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve an Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you have pain when not wearing the inserts. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided on December 5,
2019.
You asked the Plan to pay for acute inpatient hospital care. You say that you disagree with the denial. The Plan
denied your request. The Plan says the services were not medically necessary.
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 pay for acute inpatient hospital care. Our reviewer
says that the services were not medically necessary. Our physician reviewer found the enrollee presented to the
emergency room (ER) with dizziness. He denied headaches and no other associated symptoms or modifying
factors at this time. Physical exams stated member was oriented to person, place and time. He appeared welldeveloped
and well-nourished. He had no distress. The records show that the admitting physician did not
reasonably expect that the enrollee's necessary hospital care would span two midnights.
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 pay for the acute inpatient hospital care provided on December 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for intravenous infusion services provided on October 18, 2019. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says there is no documentation of a start and stop time for the service. 
 
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 96367 is intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); additional sequential infusion of a new drug/substance, up to 1 hour (List separately in addition to code for primary procedure). 
 
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 provided. Our reviewer says that the medical records provided do not include documentation of a start and stop time to corroborate the service billed. Therefore, this service cannot be verified. 
 
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 provided have not been met. Therefore, we decided that the Plan does not have to pay for intravenous infusion services provided on October 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation feature (E2300).
You asked the Plan to pre-approve the power seat elevation feature. You say that the seat lift is medically necessary. The Plan denied your request. The Plan says the elevating seat lift is not a covered item.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation feature (E2300).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair and accessories.
You asked the Plan to pre-approve a shower chair and accessories. You say that the items are necessary. The Plan denied your request. The Plan says the items are not primarily medical in nature. Therefore, coverage criteria has not been met.
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 and accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the anesthesia services provided on January 7, 2020.
You asked the Plan to waive the deductible for the anesthesia services. You say that you do not feel that two anesthesiologists should be able to bill separately during your colonoscopy. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
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 $750 deductible that applies towards anesthesia services. The anesthesia services you asked the Plan to waive the deductible for falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible that applies towards anesthesia services. The record shows you were billed separately by the providers for the anesthesia services, which are also considered separate services from the colonoscopy.
This cost sharing is a contractual obligation that had not been met at the time the anesthesia services were received on January 7, 2020. Therefore, we decided that the Plan does not have to waive the deductible for the anesthesia services provided on January 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continued rental of a continuous positive airway
pressure (CPAP) device (E0601).
You asked the Plan to pre-approve continued CPAP rental.. You say that you would like another chance to
improve you usage. The Plan denied your request. The Plan says you have not met criteria for continued rental.
The Plan must follow Medicare rules. Medicare rules say that coverage of a CPAP device after the first three
months requires evidence of adherence to use of the PAP device. Adherence to therapy is defined as use of
PAP at least 4 hours per night on 70% of nights during a consecutive thirty (30) day period anytime during the
first three (3) months of initial usage.
We looked at the file and Medicare rules. The record shows that you have not used your CPAP 4 hours or more
a night for at least 70% of nights in a 30-day period. Based on this information, we decided that Medicare rules
for coverage of continued CPAP rental. have not been met. Therefore, we decided that the Plan does not have
to pre-approve the continued rental of a continuous positive airway pressure (CPAP) device (E0601).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care and subsequent hospital care
provided from December 29, 2019 to December 31, 2019.
You asked the Plan to pay for the initial hospital care and subsequent hospital care. You say that there is no
hospital record stating the enrollee is a hospice patient. You also say that the services were emergent. The Plan
denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare
covered services related or unrelated to the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Original Medicare is responsible for payment for services until the first day of the month after the
hospice election has been revoked or terminated.
The enrollee ended Medicare Hospice benefits on December 9, 2019. The services in question were provided
before the end of that month. Therefore, we decided that the Plan does not have to pay for the initial hospital
care and subsequent hospital care provided from December 29, 2019 to December 31, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the panoramic x-ray (D0330) provided on February 6, 2020. 
 
You asked the Plan to pre-approve the panoramic x-ray. You say that you have a maximum of $3,500 per period and have not exceeded this. The Plan denied your request. The Plan says this service exceeded the frequency maximum. 
 
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, panoramic x-rays (D0330) are limited to one procedure every three plan years. The record shows that you received a panoramic x-ray on July 17, 2018 and your panoramic x-rays benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve the panoramic x-ray (D0330) provided on February 6, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the train of four testing (CPT 95999) provided on February
25, 2019.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is a bundled service.
The Plan must follow Medicare rules. Medicare rules say that all services which are integral to accomplishing a
procedure are considered a component part of a comprehensive code.
IONM services cannot be performed without TOF monitoring. This means that TOF testing is considered
integral to the performance of IONM services. As such, this component of the procedure is included in
payment for the overall IONM monitoring service which was already paid. No separate payment can be made
for this part of the service. Therefore, we decided that the Plan does not have to pay for the train of four testing
(CPT 95999) provided on February 25, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the CxBladder testing rendered on November 22, 2019.
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 the testing is not covered.
The Plan must follow Medicare rules. The rules say that the CxBladder testing is non-covered.
The test at issue is CxBladder. This test is not covered by Medicare. Therefore, we decided that the Plan does
not have to pay for the CxBladder testing rendered on November 22, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an immediate mandibular partial denture and immediate
maxillary partial denture.
You asked the Plan to pre-approve the immediate mandibular and maxillary partial dentures. You say that you
have been in pain for more than 3 months due to missing back teeth. You also say that you have not been able
to chew or eat properly. The Plan denied your request. The Plan says your plan does not cover these
procedures.
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 an
immediate mandibular partial denture and immediate maxillary partial denture.