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

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and the bitewing x-ray (D0274).

You asked the Plan to pay for the dental services. You say that your visit to the dentist was not a full year from your last visit. You say that you are asking for an accommodation for being 6 years over the 1 year. You also say that you are confused because you thought that you had coverage for 2 cleanings per year. The Plan denied your request. The Plan says 1 comprehensive oral evaluation is covered once every 3 plan years. The Plan covers 1 set of bitewing x-rays per calendar year. The Plan says that the frequency limits for these services have been exceeded. The Plan also says that cleanings are covered up to two procedures per plan year and do not need to be an exact year apart.

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 frequency limits for these services have been exceeded. The record shows that the Plan paid for these services. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and the bitewing x-ray (D0274).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a removable unilateral partial denture (D5282).
You asked the Plan to pre-approve the removable unilateral partial denture. The Plan denied your request. The Plan says this service is not covered under the enrollee's 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, 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 removable unilateral partial denture (D5282).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 12 additional Physical Therapy visits.
You asked the Plan to pre-approve the additional Physical Therapy. You say that you would like reconsideration because the additional physical therapy is medically necessary. The Plan denied your request. The Plan says the member does not meet criteria for the additional visits.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 additional Physical Therapy. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the requested services are not part of a maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain the member's current condition or to prevent or slow further deterioration. 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 additional Physical Therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve 12 additional Physical Therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for needle electromyography (95864) provided on June 15, 2020.
You asked the Plan to pay for needle electromyography. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation does not support the service 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 95864 is needle electromyography; 4 extremities with or without related paraspinal areas. We asked our coder 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 needle electromyography. Our reviewer says that CPT code 95864 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided do not include documentation of a Needle electromyograpyhy, 4 extremities with or without related paraspinal areas being performed on June 15, 2020, 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 needle electromyography have not been met. Therefore, we decided that the Plan does not have to pay for needle electromyography (95864) provided on June 15, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services.

You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says the enrollee must receive care from a network provider. In most cases, care received from an out of network provider will not be covered.

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 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 laboratory services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown lengthening and periodontal evaluation you received from September 8, 2020, to September 14, 2020.
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says this 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 services are not among those covered under this benefit. The Plan covers only those dental services listed in the Evidence of Coverage. Crown lengthening and periodontal evaluations are not covered. Therefore, we decided that the Plan does not have to pay for the crown lengthening and periodontal evaluation you received from September 8, 2020, to September 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electric platform/elevator (E1399) to be installed on your porch.
You asked the Plan to pre-approve this item. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says this item is not a covered benefit under your contractual policy or by Medicare.
The Plan covers all items that Medicare covers. Medicare rules state that elevators are not covered because they considered convenience items that are not primarily medical in nature. While an electric platform/elevator may be appropriate for you 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 an electric platform/elevator (E1399) to be installed on your porch.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the infusion supplies (A4222) Ambulatory infusion pump (E0781) provided April 1, 2020 to April 22, 2020
You asked the Plan to pay for the infusion services. You say that you are a DME company and have no ready access to records. You are asking that the open claims attached be reviewed and considered with the physicians written order. The Plan denied your request. The Plan says the services provided is inclusive under services approved and paid to the attending Oncologist.
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, we find that the payment is bundled in the physician's payment. Payment for you is the responsibility of the physician. Based on this information, we decided that Medicare rules for coverage of the infusion services have not been met. Therefore, we decided that the Plan does not have to pay for the infusion supplies (A4222) Ambulatory infusion pump (E0781) provided April 1, 2020 to April 22, 2020
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.

You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the does not require an interdisciplinary, comprehensive rehabilitation program as she does not present with a complex medical or rehab pathology.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for small bowel obstruction and appendicitis which was treated surgically. The enrollee's medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a laparoscopic total hysterectomy.
You asked the Plan to pre-approve a laparoscopic total hysterectomy. You say that your seizures are severe during your monthly cycle and your doctor has recommended this surgery. The Plan denied your request. The Plan says that sterilization procedures are non-covered by Medicare.
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 laparoscopic total hysterectomy. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Amenorrhea is not an indication for hysterectomy. A complete workup for amenorrhea has not been done. Amenorrhea is usually treated with medications. There are hormonal contraceptives that the patient can take with her seizure medications working in conjunction with her neurologist. Worsening seizures during menses is not an indication for hysterectomy per se as many medical therapies will suppress ovulation and menstruation. The patient has not tried and failed any medical therapies for this. There is no evidence in the medical record that the patient is suffering from heavy menstrual bleeding or other abnormal uterine bleeding. Fear of future ectopic alone is not an indication for salpingectomy. Our physician reviewer found that your condition does not meet criteria for coverage of a laparoscopic total hysterectomy. 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 laparoscopic total hysterectomy have not been met. Therefore, we decided that the Plan does not have to pre-approve a laparoscopic total hysterectomy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided by an OON provider.

You asked the Plan to pay for the dental services. You say that the provider is in-network. The Plan denied
your request. The Plan says the provider is not in-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.

We contacted the Plan and verified that 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 dental
services provided by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite of two surfaces.

You asked the Plan to pay for the resin-based composite of two surfaces. You say that you confirmed with the
Plan that the treating provider was in-network prior to the services being rendered. The Plan denied your
request. The Plan says the Plan has already issued reimbursement for two fillings on this claim, and the
enrollee's restoration is exhausted.

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, restorations (fillings) are limited to two
procedures per calendar year. The record shows that the enrollee received three resin-based composites, two of which were covered by the Plan, and the enrollee's restorations benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the resin-based composite of two surfaces.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator (E0466).
You asked the Plan to pre-approve a home ventilator. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that ventilators (E0465, E0466) are covered for specific conditions.
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 home ventilator. Our reviewer says that the item is not medically necessary. Our physician reviewer found while the E0466 is covered for chronic respiratory failure consequent to chronic obstructive pulmonary disease (COPD), it is not clear that that coverage criteria have been met in this case have been met. The results of a repeat arterial blood gas (ABG) are not documented, and there are no documented trials of continuous positive airway pressure therapy (CPAP) or bilevel positive airway pressure (BiPAP). 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 home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator (E0466).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe periodontal maintenance (D4910) and the gingival irrigation (D4921 x 4) provided on October 6, 2020.You asked the Plan to pay forthe dental services. You say that all of these charges were accepted the previous year. You also say that you do not understand why you need to appeal every single year.The Plan denied your request. The Plan says there is an annual maximum of $1,000 for covered dental services. The Plan also says that the annual maximum has been exhausted.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 annual maximum of $1,000 has been exhaustedprior to this date of service.Date of ServiceTotal BilledTotal AllowedPlan PaidYour Responsibility6/5/2020$376$229$229$07/28/2020$290$144$144$08/11/2020$1,267$743$627$116TOTAL:$1,000Additionally, the Evidence of Coverage clearly states that after the annual maximum is exhausted, any remaining charges are your responsibility.Therefore, we decided that the Plan does not have to pay forthe periodontal maintenance (D4910) and the gingival irrigation (D4921 x 4) provided on October 6, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an outpatient Kyphoplasty (CPT code 22513), for the enrollee.
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.
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 services. Our physician reviewer found the criteria for kyphoplasty are not met. Kyphoplasty remains controversial for thoracic tumor fractures. More research is needed. 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 pre-approve an outpatient Kyphoplasty (CPT code 22513), for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve prostatic artery embolization (PAE) for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says Medicare does not cover services that are experimental, investigational, or unproven.

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 the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found prostatic arterial embolization (PAE) is an experimental technique to treat symptomatic benign prostatic hypertension (BPH). Very limited studies have demonstrated possible short-term safety and efficacy. The most recent American Urological Association guidelines do not recommend this procedure outside of a clinical trial 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve prostatic artery embolization (PAE) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from September 7, 2020, to September 16, 2020.

You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you had no choice in which hospital you were taken to. The Plan denied your request. The Plan says the copayments were 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). Your contract with the Plan clearly says that you must pay a $390 copayment per day, days 1 to 5, for an in-network inpatient hospital stay. 

You have been asked to pay a total of $1,950 ($390 copayment x 5 days = $1,950) for the inpatient hospital stay. This service falls within the Inpatient hospital care 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 copayment for the inpatient hospital stay provided from September 7, 2020, to September 16, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the ESRD services.

You asked the Plan to pay for the ESRD services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says an occurrence code and dates are required due to the condition code on this claim.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ESRD services have not been met. Specifically, the claim has not been submitted with the required occurrence code and dates. Therefore, we decided that the Plan does not have to pay for the ESRD services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a post and crown (D2954, D2751) for tooth #6.
You asked the Plan to pre-approve the post and crown. You say that these dental services are medically necessary. The Plan denied your request. The Plan says the benefit for this service has been exhausted.
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 plan covers one crown or related service per tooth per 5 plan years. The record shows a previous crown was placed on tooth # 6 on October 16, 2020. Therefore, we decided that the Plan does not have to pre-approve a post and crown (D2954, D2751) for tooth #6.