Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services provided on August 12, 2020, by an out-of-network (OON) provider.You asked the Plan to pay forthe laboratory services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services rendered are not a covered benefit.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 has network providers available who can provide 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 forthe laboratory services provided on August 12, 2020, by an out-of-network (OON) provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea pneumatic compression device (E0652) and segmental pneumatic appliance, full leg (E0667x2).You asked the Plan to pre-approvea pneumatic compression device and appliance. You say that you have been trying to get approval for the last 2 years as this device is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet the LCD criteria for an advanced lymphedema pump as there is no failed four week trial of a basic pneumatic compression device of either E0650 or E0651.The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. 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, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.Therefore, we decided that the Plan does not have to pre-approvea pneumatic compression device (E0652) and segmental pneumatic appliance, full leg (E0667x2).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM).
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 covered.
The Plan must follow Medicare rules. Medicare rules say that a CGM is covered when specific criteria are met. We looked at the file and Medicare rules. The file shows that you are not insulin-treated. 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 a therapeutic continuous glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the porcelain/ceramic crown (D2740).
You asked the Plan to pre-approve the porcelain/ceramic crown. You say that this service is medically
necessary. The Plan denied your request. The Plan says this service exceeds the maximum count allowed per period.
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
porcelain/ceramic crown once per tooth every five years.
We looked at the file and Medicare rules. The file indicates that you last had this service performed on the
same tooth in September 2018. Therefore, you have exhausted your Plan benefit. Based on this information, we
decided that the Plan's rules for coverage of the porcelain/ceramic crown have not been met. Therefore, we
decided that the Plan does not have to pre-approve the porcelain/ceramic crown (D2740).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora Contour Next Test in Vitro Strips, non-preferred brand test strips.You asked the Plan to pay fora Contour Next Test in Vitro Strips, non-preferred brand test strips. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the documentation does not support that the enrollee is unable to use a preferred test strip.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that enrollees must receive diabetic testing supplies from specific brands.The requested diabetic testing strips is not a LifeScan branded product. The Plan has preferred brands available who can provide the items 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 fora Contour Next Test in Vitro Strips, non-preferred brand test strips
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve upper and lower dentures.
You asked the Plan to pre-approve the dentures. You say that this should be reconsidered. The Plan denied
your request. The Plan says the denture benefit 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. The Plan covers dentures once
every five years.
Dentures were last received less than five years ago on August 29, 2016 and November 15, 2018. Based on this
information, we decided that the Plan's rules for coverage of the dentures have not been met. Therefore, we
decided that the Plan does not have to pre-approve upper and lower dentures.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveincontinence supplies.You asked the Plan to pre-approveincontinence supplies. The Plan denied your request. The Plan says this item is not a covered benefit.The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items.Therefore, we decided that the Plan does not have to pre-approveincontinence supplies.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Laminectomy (63047) to be rendered by the out of network (OON) provider.You asked the Plan to pre-approvethis service. You say that a Laminectomy is medically necessary for the enrollee.The Plan denied your request. The Plan says that there are contracted providersavailable to performtherequestedservice.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 service at issue in this appeal. We found no exception that would require the Plan to pre-approve this service.Therefore, we decided that the Plan does not have to pre-approvea Laminectomy (63047) to be rendered by the out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvethe Superion interspinous spacer for the enrollee.You asked the Planto pre-approvethe spacer. You say that this is medically necessary.The Plandenied your request. The Plansaysa review of the current medical literature indicates that this service is considered experimental and investigational.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 spacer. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the spacer is experimental. More research is needed to show safety and efficacy.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 spacer have not been met.Therefore, we decided that the Plandoes not haveto pre-approvethe Superion interspinous spacer for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvean electric wheelchair lift for a vehicle.You asked the Planto pre-approvethe lift. You say that you have a hard time getting in andout of the vehicle.The Plandenied your request. The Plansaysthis item is not considered durable medical equipment.The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home.Therefore, we decided that the Plandoes not haveto pre-approvean electric wheelchair lift for a vehicle.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan has to pre-approve the manual wheelchair. We decided that the Plan does not have to pre-approve the accessories. 

You asked the Plan to pre-approve the manual wheelchair and accessories. You say that this is medically necessary to ambulate at home and to and from medical appointments.The Plan says that this is not medically necessary.
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 need new orthopedic 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core buildup 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 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. The Plan covers the services
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 services.
The requested services are not listed as covered benefits in the Evidence of Coverage. Based on this
information, we decided that the Plan's rules for coverage of the services have not been met. Therefore, we
decided that the Plan does not have to pre-approve core buildup for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (CPT 11046) provided to the enrollee on
May 15, 2020.
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 CPT 11046 was not billed an acceptable primary procedure code.
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 11046 is "Debridement, muscle and/or fascia (includes
epidermis, dermis, and subcutaneous tissue, if performed."
We asked our coding reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the
services at issue in this case were not supported by the medical records. Our coding reviewer found the medical
documentation and claim information notes that CPT 11046 was billed independent any other code. CPT 11046
is an add-on code and is only eligible for reimbursement if it is billed alongside the CPT code for the primary
procedure.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not
have to pay for surgical services (CPT 11046) provided to the enrollee on May 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe ophthalmology services to be provided by an out of network provider.You asked the Plan to pre-approvethe ophthalmology services from an out of network provider. You say that the out-of-network ophthalmologist knows your medical history.The Plan denied your request. The Plan says they have in-network providers who can treat you.Medicare rules say that plans can require enrollees to getcare 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-approvethe ophthalmology services to be provided by an out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a core buildup 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 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 items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a
core buildup for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forinjection services (CPT 27096) provided to the enrollee on July 16, 2020.You asked the Plan to pay forthe services. You say that this should be paid for.The Plan denied your request. The Plan says CPT 27096 has an MUE value of 1, and 2 units were 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 27096 is "Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance.We asked our coding reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not supportedby the medical records. Our coding reviewer found Medicare guidelines for CPT 27096 has a MAI Adjudication Indicator of 2, which allows for a maximum allowable number of units that can be billed by the same provider on the same day of service as 1 unit. Because the provider billed this procedure with an RT LT modifier on the same line and 2 units of service on the same day it was not billed according to Medicare rules with procedures with an MUE of "2".We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plan does not have to pay forinjection services (CPT 27096) provided to the enrollee on July 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe complete series of intraoral x-rays, comprehensive oral evaluation, extraction, problem focused limited oral evaluation, fixed partial denture section, first 15 minutes of deep sedation/general anesthesia, each subsequent 15 minute increment of deep sedation/general anesthesia, and therapeutic parenteral drug provided from July 15, 2020, to July 28, 2020.You asked the Plan to pay forthe complete series of intraoral x-rays, comprehensive oral evaluation, extraction, problem focused limited oral evaluation, fixed partial denture section, deep sedation/general anesthesia services, and therapeutic parenteral drug. You say that you only had one tooth extraction, and received a bill for $1,140.00.The Plan denied your request. The Plan says your benefits for the complete series of intraoral x-rays and comprehensive oral evaluation have been satisfied and the frequency limitations have been exceeded, and you were charged correctly for the extraction. The Plan also says that the problem focused limited oral evaluation, fixed partial denture section, deep sedation/general anesthesia services, and therapeutic parenteral drug are not covered benefits.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, problem focused limited oral evaluation, fixed partial denture section, first 15 minutes of deep sedation/general anesthesia, each subsequent 15 minute increment of deep sedation/general anesthesia, and therapeutic parenteral drug are not among those 
covered under this benefit. The Plan contract says that full mouth or panoramic x-rays are limitedto one procedure every five years. The record shows that you received a panoramic x-rayon February 18, 2020, and your full mouth or panoramic x-raysbenefit has been exhausted. The Plan contract says that comprehensive oral evaluation is limited to one procedure every three years. The record shows that you received a comprehensive oral evaluation on February 18, 2020, and your comprehensive oral evaluation benefit has been exhausted. The Plan contract also clearly states that you are responsible for a 50%coinsurance for extractions.Therefore, we decided that the Plan does not have to pay forthe complete series of intraoral x-rays, comprehensive oral evaluation, extraction, problem focused limited oral evaluation, fixed partial denture section, first15 minutes of deep sedation/general anesthesia, each subsequent 15 minute increment of deep sedation/general anesthesia, and therapeutic parenteral drug provided from July 15, 2020, to July 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe Alpha Stim device, miscellaneous durable medical equipment (E1399).You asked the Plan to pre-approvethe Alpha Stim device. You say that you are requesting a standard appeal as you would very much appreciate the opportunity to provide the necessary documentation to support the need of this device.The Plan denied your request. The Plan says this service is experimental and investigational as there is not enough medical evidence that shows that this devices helps treat your depression and chronic pain.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Alpha Stim device have not been met.Therefore, we decided that the Plan does not have to pre-approvethe Alpha Stim device, miscellaneous durable medical equipment (E1399).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvecore buildup and prefabricated post and core.You asked the Planto pre-approvethe dental services. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is not a covered benefit.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plandoes not haveto pre-approvecore buildup and prefabricated post and core
Appeal type: SNF
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to a skilled nursing facility (SNF).You asked the Planto pre-approvethe admission. You say that this is medically necessary.The Plandenied your request. The Plansaysservices can be received at the IRF.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not requireskilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the admission have not been met.Therefore, we decided that the Plandoes not haveto pre-approveadmission to a skilled nursing facility (SNF).