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

We decided that the Plan does not have to pre-approve a Q-Logic joystick (K0108) for a power wheelchair.

You asked the Plan to pre-approve the joystick. You say that this is medically necessary. The Plan denied your request. The Plan says this code is already included in the payment for E2377, and should not be requested separately.

The Plan must follow Medicare rules. The rules say that K0108 would be included in the payment for an expandable controller (E2377). 

There is no reason to bill K0108 separately in this case. Based on this information, we decided that Medicare rules for coverage of the joystick have not been met. Therefore, we decided that the Plan does not have to pre-approve a Q-Logic joystick (K0108) for a power wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the debridement services provided on December 9, 2020.

You asked the Plan to pay for the debridement services. You say that you disagree with the plan's denial. The Plan denied your request. The Plan says the services billed are not considered 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 debridement services have not been met. Specifically, medical records were not provided for review in this case. The record shows that the Plan made multiple attempts to secure medical records, without success. Without medical records, we cannot determine if Medicare criteria are met in this case. Therefore, we decided that the Plan does not have to pay for the debridement services provided on December 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pontic (D6240) for tooth #21 and retainer crowns (D6750) for tooth #'s 20 and 22.

You asked the Plan to pre-approve the pontic and retainer crowns. You say that you did not receive a partial denture in 2019. The Plan denied your request. The Plan says these services are not medically necessary.

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 covers the pontic and retainer crowns when the services are medically necessary and reasonable.

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 pontic and retainer crowns. Our reviewer says that the criteria for fixed bridgework has not been met. Our physician reviewer found there are no posterior teeth on the right side of the arch, and tooth #'s 17 to 19 are also missing on the lower arch.

The Plan provides that "The placement of a fixed prosthetic appliance will only be considered for the anterior segment of the mouth in those exceptional cases where there is a documented physical or neurological disorder that would preclude placement of a removable prosthesis, or in those cases requiring cleft palate stabilization. The placement of a fixed prosthetic appliance will only be considered for the anterior segment of the mouth to replace a single maxillary anterior tooth or replace two adjacent mandibular teeth. Fixed prosthetic appliances are not a benefit when there is one or more missing posterior teeth in the same arch. The use of double abutments will not be approved." In this instance the missing tooth to be replaced is a posterior tooth, #21. The Plan limitations do not provide for replacement of posterior teeth on a fixed bridge.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the pontic and retainer crowns have not been met. Therefore, we decided that the Plan does not have to pre-approve a pontic (D6240) for tooth #21 and retainer crowns (D6750) for tooth #'s 20 and 22.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the four periodontal scalings and root planings (D4341 x4) provided on April 15, 2021 by an OON provider.

You asked the Plan to pay for the scalings and planings. You say that you were seen by this provider on January 25, 2021 as a 3-month courtesy but were not aware. You also say that you did not receive the deep cleanings until April 15, 2021, which was after the 3-month courtesy period ended. The Plan denied your request. The Plan says services are only covered by your plan for in-network dentist. The Plan also says that the treating provider is not in-network.

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 OON. Therefore, we decided that the Plan does not have to pay for the four periodontal scalings and root planings (D4341 x4) provided on April 15, 2021 by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Vitamin D; 25 hydroxy, includes fraction(s) (CPT code 82306) provided to the enrollee on February 4, 2021.

You asked the Plan to pay for the testing. You say that the claim should be paid. The Plan denied your request. The Plan says the Medicare rules have not been met.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The services are not authorized because code 82306 is not a Medicare benefit for the diagnosis listed on the claim and is done for screening purposes. Therefore, we decided that the Plan does not have to pay for Vitamin D; 25 hydroxy, includes fraction(s) (CPT code 82306) provided to the enrollee on February 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.

You asked the Plan to pre-approve a shower chair. You say that this equipment is necessary because you are afraid of falling. The Plan denied your request. The Plan says this is a non-covered item.

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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Group 3 power wheelchair electronic upgrades.
You asked the Plan to pre-approve power wheelchair expandable controller (E2377), power wheelchair expandable controller harness (E2313), power wheelchair electronic connection (E2311). You say that you need a Group 3 power wheelchair and accessories. The Plan denied your request. The Plan says documentation does not show that you have upper limb weakness that would affect your ability to use the switches that come with the approved power options.
The Plan must follow Medicare rules. The rules say options and accessories for wheelchairs are covered if the beneficiary has a wheelchair that meets Medicare coverage criteria and the option/accessory itself is medically necessary. 
The approved power options come with their own switches. The record shows your upper limb strength and function are adequate for you 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 the Group 3 power wheelchair upgraded electronics.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy services to be provided by the requested out-of-network provider.
You asked the Plan to pre-approve physical therapy services. The Plan denied your request. The Plan says there is no medical reason why you cannot return to the network provider for reassessment to see if skilled therapy is needed at this time.
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 the requested out-of-network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the continued stay at a skilled nursing facility (SNF) provided from September 19, 2020, to October 9, 2020.

You asked the Plan to pay for the continued stay. You say that you were advised you signed off approving private pay for the dates of service in this case. You say that you were not aware of what you were signing. You say that you still required therapy and constant care at the time. You also say that you were not competent enough to be able to sign off on anything. The Plan denied your request. The Plan says the enrollee has plateaued in therapy. The Plan also says that the enrollee was aware that the services would not be covered as prior authorization was denied.

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 pay for the continued stay. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 continued stay have not been met. Therefore, we decided that the Plan does not have to pay for the continued stay at a skilled nursing facility (SNF) provided from September 19, 2020, to October 9, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services (CPT 29876) provided to the enrollee on October 16, 2020.

You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your request. The Plan says the records do not support the services 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 29876 is "surgical knee arthroscopic major synovectomy, 2 or more compartments (medial or lateral)."

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 medical records provided does not include sufficient documentation to validate that an arthroscopy, knee, surgical; synovectomy, major, 2 or more compartments (eg, medial or lateral) was performed on October 16, 2020, therefore this service cannot be verified.

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 the surgical services (CPT 29876) provided to the enrollee on October 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two osseous surgeries (D4261 x2), three surgical placements of implant bodies: endosteal implants (D6010 x3), three surgical accesses to an implant body (D6011 x3), sinus augmentation with bone or bone substitutes (D7951), sinus augmentation via a vertical approach (D7952), and bone replacement graft for ridge preservation (D7953).

You asked the Plan to pre-approve the osseous surgeries, endosteal implants, surgical accesses to an implant body, sinus augmentations, and bone replacement graft. You say that you need these services to be approved for coverage. The Plan denied your request. The Plan says these services are not covered under your benefit package.

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 two osseous surgeries (D4261 x2), three surgical placements of implant bodies: endosteal implants (D6010 x3), three surgical accesses to an implant body (D6011 x3), sinus augmentation with bone or bone substitutes (D7951), sinus augmentation via a vertical approach (D7952), and bone replacement graft for ridge preservation (D7953).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional personal care assistant (PCA) hours.

You asked the Plan to pre-approve additional PCA hours. You say that you were originally approved for 18.5 hours. You say that you need more. You also say that now they are being decreased even more. The Plan denied your request. The Plan says the requested additional PCA hours exceed the amount of time required based on your current living situation. The Plan also says that no special circumstances were identified.

The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from trained medical or paramedical staff, is not covered. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional PCA hours have not been met. Specifically, we find that the services at issue in this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve additional personal care assistant (PCA) hours.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve laser vision correction surgery.

You asked the Plan to pre-approve laser eye surgery. You say that you need to have this surgery done but cannot afford it. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this surgery is not covered by Medicare or the Plan's vision benefits.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan does not cover laser vision correction surgery. 

We looked at the file and the Plan's rules. This service is not covered by the Plan's supplemental vision benefits. Based on this information, we decided that the Plan's rules for coverage of laser eye surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve laser vision correction surgery.
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 service is medically necessary. The Plan denied your request. The Plan says the service is 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled nursing or therapy needs. 
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. Specifically, medically necessary services can be provided at a lower level of care. This means SNF care is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the molecular pathology procedure for the breast cancer gene (BRCA).
You asked the Plan to pre-approve the molecular pathology procedure for BRCA. You say that this request should be considered medically necessary due to a family history of breast cancer. The Plan denied your request. The Plan says the coverage criteria for the requested pathology procedure have not been met.
The Plan must follow Medicare rules. Medicare rules say that the requested BRCA pathology procedure is medically necessary for a current diagnosis or a personal history of cancer. 
We looked at the file and Medicare rules. In this case, the information we have indicates that you do not have a personal history of cancer or a current diagnosis of cancer. Based on this information, we decided that Medicare rules for coverage of the molecular pathology procedure for BRCA have not been met. Therefore, we decided that the Plan does not have to pre-approve the molecular pathology procedure for the breast cancer gene (BRCA).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the removal of an impacted tooth (D7230) provided on March 31, 2021.

You asked the Plan to pay for the removal of an impacted tooth. You say that this service was provided due to an emergency. The Plan denied your request. The Plan says teeth extractions are covered when preparing the jaw for radiation treatments of neoplastic cancer disease. The Plan also says that you did not have any additional dental coverage on your policy to cover the tooth extraction.

Medicare generally does not cover dental services. The Plan follows the same rule. 

The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the removal of an impacted tooth (D7230) provided on March 31, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a seat lift chair.

You asked the Plan to pre-approve a seat lift chair (E1399) and seat lift mechanism (E0627). You say that the enrollee needs a power seat lift chair due to back pain. The Plan denied your request. The Plan says the power seat lift chair is for convenience not a medical necessity.

The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed in the Medicare rules section are met. Medicare does not cover the upholstered portion of a seat lift chair. 

We looked at the file and Medicare rules. The notes indicate the enrollee is able to independently transfer from sit-to-stand from a standard height chair. Based on this information, we decided that Medicare rules for coverage of a seat lift chair (E1399) and seat lift mechanism (E0627) have not been met. Therefore, we decided that the Plan does not have to pre-approve a seat lift chair.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the EKG provided on March 3, 2021.

You asked the Plan to waive the copayment for the EKG. You say that you feel you should not be responsible for the copayment because you were ordered by the surgeon to go to your primary care doctor to have an EKG for surgery. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.

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 $5 copayment for diagnostic laboratory services and diagnostic procedures and tests (per day, per facility). This excludes basic and advanced diagnostic imaging services.

You have been asked to pay a $5 copayment for the EKG. The EKG falls within the "Outpatient diagnostic tests and therapeutic services and 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 copayment for the EKG provided on March 3, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional routine transportation mileage.
You asked the Plan to provide coverage for additional routine transportation mileage. The Plan denied your request. The Plan says one way this is 105 miles, which is 55 miles over what benefit allows
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
We looked at your request, the records in the case file, and the rules. The file shows that a one-way trip to the location you requested exceeds the Plan benefit by 55 miles.
Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to provide coverage for additional routine transportation mileage.