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

We decided that the Plan does not have to pre-approve a seat elevator feature (E2300) for a power wheelchair.
You asked the Plan to pre-approve the seat elevator feature. You say that this feature is medically necessary. The Plan denied your request. The Plan says this feature is not covered under Medicare rules.
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature (E2300) and power standing feature (E2301) are non-covered because they are not primarily medical in nature. We looked at the file and Medicare rules. The requested power seat elevator is not a covered benefit. Based on this information, we decided that Medicare rules for coverage of the seat elevator feature have not been met. Therefore, we decided that the Plan does not have to pre-approve a seat elevator feature (E2300) for a power wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), pulp
vitality tests (D0460), endodontic therapy (D3330), and treatment of root canal obstruction (D3331) provided
on March 30, 2021 by an OON provider.

You asked the Plan to pay for the problem focused limited oral evaluation, pulp vitality tests, endodontic
therapy, and treatment of root canal obstruction. You say that you discussed an amount of $999 with the
provider for a root canal and then were charged $2,173. The Plan denied your request. The Plan says services
performed by an OON provider are not covered because your healthcare plan does not have OON 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, you are responsible for 100% of the
cost for dental services rendered by an OON provider. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), pulp vitality tests (D0460), endodontic therapy (D3330), and treatment of root canal obstruction (D3331) provided on March 30, 2021 by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient behavioral health services.
You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says there are no unstable medical issues that require 24-hour care.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. Continued inpatient care was requested. 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 continued services. Our physician reviewer found that the services are not reasonably expected to improve your condition or for the purpose of diagnosis. Based upon review the records provided, acute inpatient mental health treatment is not medically necessary as you are not shown to be a danger to yourself or others. You were without agitation or aggression and without perceptual disturbance including auditory or visual hallucinations.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient behavioral health services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve consultation and office visits to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve consultation and office visits. You say that this request is medically necessary to see what other options are available. The Plan denied your request. The Plan says there are in-network providers available that will be able to offer a second opinion on your condition.

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 consultation and office visits to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation services. 
 
You asked the Plan to pre-approve the requested services. You say that two levels of treatment would not 
achieve desired pain relief for the enrollee. The Plan denied your request. The Plan says the request does not 
meet criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that facet joint interventions are only covered under 
certain medical indications.   
 
We looked at the file and Medicare rules. The records show that the enrollee received radiofrequency ablation 
services on January 19, 2021, and July 27, 2021. For each covered spinal region, no more than two 
radiofrequency sessions will be reimbursed per rolling 12 months.  

Based on this information, we decided that Medicare rules for coverage of the requested services have not been 
met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the 3-surface filling (D2332), the single-surface filling (D2330), and NM gross receipts (D0001) provided on October 2, 2020.
You asked the Plan to reimburse you for the dental services. You say that you asked the office manager to bill your plan. You say that you were advised that they do not deal with Medicare. You also say that you feel you should be reimbursed for these services. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that fillings are listed as covered services. The Plan says that you are responsible for the difference between the INFS and dentists' charged fees when visiting an out of network dentist. The Plan also says that D0001 is not a valid code and payment cannot be made.
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, out of network dentists have not agreed to provide services at contracted fees.

Procedure Code
Billed Amount
Allowed Amount
Difference
Your Responsibility

D2330
$342
$175
$167
$167

D2332
$182
$85
$97
$97

D0001
$31.44
$0
$31.44
$31.44
TOTAL:
$295.44

Therefore, we decided that the Plan does not have to reimburse you for the 3-surface filling (D2332), the single-surface filling (D2330), and NM gross receipts (D0001) provided on October 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and the extra-oral posterior dental radiographic image (D0251) provided on April 22, 2021.
You asked the Plan to pay for the dental services. You say that prior to your appointment you called the plan to see what was covered. You say that you were led to believe that you would be covered. You say that the representative advised that services were covered based on how they were coded. You also say that you are on a fixed income and not prepared to for this bill. The Plan denied your request. The Plan says limited oral evaluation is not listed as a covered service. The Plan says that extra-oral posterior dental radiographic image is not listed as a covered service either. The Plan also says that prior to receiving the service, you signed a pay agreement stating you would be responsible to pay for any non-covered services you received.
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 limited oral evaluation and the extra-oral posterior dental radiographic image 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) and the extra-oral posterior dental radiographic image (D0251) provided on April 22, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy services to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve OON services. The Plan denied your request. The Plan says in-network options 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physical therapy services to be provided by an out-of-network (OON) provider
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 you disagree with the denial. 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 requested Intracept procedure is experimental in nature for the treatment of low back pain. 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgical services (49320, 44120, 44180) to be provided by an out-of-network provider.
You asked the Plan to pre-approve the surgical services. You say that the requested provider has followed your case for some time, and you would like them to perform the surgery. The Plan denied your request. The Plan says there are network providers capable of performing the procedure at issue.
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 surgical services (49320, 44120, 44180) to be provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on April 22, 2021.
You asked the Plan to pay for the problem focused limited oral evaluation. The Plan denied your request. The Plan says this service exceeds the frequency limitation in your benefit 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, problem focused limited oral evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem focused limited oral evaluation (D0140) on March 31, 2021 and your problem focused limited oral evaluation (D0140) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on April 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the diagnostic casts (D0470) and maxillary immediate denture (D5130) provided on January 18, 2021, and February 3, 2021.
You asked the Plan to pay for the diagnostic casts and maxillary immediate denture. You say that you would like to appeal these services. The Plan denied your request. The Plan says these services are not covered under your plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the diagnostic casts (D0470) and maxillary immediate denture (D5130) provided on January 18, 2021, and February 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the visual field assessment monitoring device (0349T)
to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the monitoring services. You say that this service is not only medically
necessary for the enrollee based on the attached medical records but is also a service that is covered by
Medicare and many other health insurers. The Plan denied your request. The Plan says enrollee's must receive
their medical services from an in-network provider with the exception being urgent or emergent services. Nonemergent
services with non-contracted providers require prior authorization before services being rendered.
The device also is not covered as it has not been given full FDA approval.
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 pre-approve these items/services.
Therefore, we decided that the Plan does not have to pre-approve the visual field assessment monitoring device
(0349T) to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical exam provided on March 26, 2021.
You asked the Plan to pay for periodic comprehensive preventive medicine reevaluation and management (99397). You say that this exam was ordered by your doctor as a preparatory exam for surgery requiring general anesthesia. The Plan denied your request. The Plan says according to your benefits you can get one routine physical exam each year.
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of one routine physical exam annually. Based on review of the file, a physical exam was provided in the same year as the exam at issue in this case. Therefore, we decided that the Plan does not have to pay for the physical exam provided on March 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor

You asked the Plan to pre-approve the requested device. The Plan denied your request. The Plan says coverage criteria have not been met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic continuous glucose monitors are only covered under certain medical indications.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this information, we decided that Medicare rules for coverage of the requested device have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aduhelm. 
 
You asked the Plan to pre-approve Aduhelm. You say that this requested drug is medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says this drug is considered investigational for the 
enrollee's condition and is excluded from coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Aduhelm. Our reviewer says that the 
requested drug is not medically necessary and reasonable. Our physician reviewer found the document ation is 
insufficient to demonstrate that the enrollee has a diagnosis of Alzheimer's disease. It has not been shown that 
Aduhelm (Aducanumab) is at least as beneficial as existing and appropriate and available medically 
appropriate alternatives for this enrollee's condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Aduhelm have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aduhelm.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the enrollee needs to continue rehabilitation at a subacute level of care. The Plan denied your request. The Plan says the enrollee can continue to be cared for at the current rehabilitation hospital.
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 SNF care. Our reviewer says that SNF admission is not appropriate at this time. Our physician reviewer found based on the medical records provided this patient does not require the services on an inpatient basis, only in a skilled nursing facility setting. Continued care in the acute inpatient rehabilitation facility is appropriate until the patient is stable to transfer to a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the reline of a complete mandibular denture (D5751) provided on March 25, 2021.
You asked the Plan to pay for the reline of a complete mandibular denture. You say that the dental office advised that there would be no charge to you. You also say that you told them if there was any charge to you that you did not want to get the realignment done. The Plan denied your request. The Plan says benefits for this service have been satisfied and the frequency limitation has been exceeded.
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, denture reline and is limited to one procedure code per calendar year. The record shows that you received a reline of a complete maxillary denture (D5750) that was covered in full on March 25, 2021 and your denture reline benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the reline of a complete mandibular denture (D5751) provided on March 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device provided on January 26, 2021.

You asked the Plan to pay for the pneumatic compression device (E0676). You say that the device was prescribed so you should be compensated. The Plan denied your request. The Plan says the pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery.

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 a pneumatic compression device provided on January 26, 2021.