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

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652).

You asked the Plan to pre-approve a pneumatic compression device. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria.

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-approve a pneumatic compression device (E0652).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the complete upper denture (D5110).

You asked the Plan to pre-approve the complete upper denture (D5110). The Plan denied your request. The
Plan says the service is only covered once every five plan years.

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 also have a maximum benefit of
one complete upper denture every five plan years. The Plan paid for a complete upper denture provided on June
11, 2020, which exhausted your benefit. Therefore, we decided that the Plan does not have to pre-approve the
complete upper denture (D5110).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 12 acupuncture visits.
You asked the Plan to pre-approve the visits. You say that you have pain throughout your spine. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year.
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, the records do not show that the requested acupuncture services are for the treatment of chronic low back pain. Therefore, we decided that the Plan does not have to pre-approve 12 acupuncture visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve a consultation with an OON provider. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the services requested are neither emergent nor urgent to seek out-of-network care. The Plan says there are equally qualified in-network Neurologist's available to you that can provide the services you are requesting.

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 a consultation 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 auricular nerve stimulator.
You asked the Plan to pre-approve an implantable neurostimulator, pulse generator, any type (L8679) and
Percutaneous implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve) (64555).
You say that you have tried injections, splint and medication management, none of which has worked. The
Plan denied your request. The Plan says this device is not covered by Medicare or the Plan.
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 an implantable neurostimulator, pulse generator, any type (L8679) have not been met. Therefore,
we decided that the Plan does not have to pre-approve an auricular nerve stimulator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a reline of complete upper denture (D5750).

You asked the Plan to pre-approve a reline of complete upper denture. You say that you want the Plan to pre-approve
this service. The Plan denied your request. The Plan says the service at issue 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
reline of complete upper denture (D5750).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental pneumatic appliance (E0667).
You asked the Plan to pre-approve a pneumatic compression device and appliance. You say that you disagree with this determination and ask the plan to review the enclosed documentation supporting medical necessity of the requested equipment. 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-approve a pneumatic compression device (E0652) and segmental pneumatic appliance (E0667).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve custom foot orthotics.
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.
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 fo
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill that includes transportation for non-medical needs, an allowance for healthy food purchases and/or electricity, water and/or phone bill payments (debit card), home assistance services (repairs).

You asked the Plan to pre-approve special supplemental benefits for the chronically ill that includes transportation for non-medical needs, an allowance for healthy food purchases and/or electricity, water and/or phone bill payments (debit card), home assistance services (repairs). The Plan denied your request. The Plan says the enrollee has none of the qualifying diagnoses, does not require intense care coordination, and has no high risk for hospitalizations or high risk for adverse health outcomes.

The Plan contract says that, in order to be eligible for special supplemental benefits for the chronically ill, you must have one or more comorbid and medically complex chronic conditions that are life-threatening or significantly limit your health or general functioning. In addition, you must have a high risk of hospitalization or other adverse health outcomes; and must require intensive care coordination.

We looked at the file and Plan's rules. The file shows that your medical conditions are not eligible medical conditions for coverage under the Plan's benefit. Therefore, we decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill that includes transportation for non-medical needs, an allowance for healthy food purchases and/or electricity, water and/or phone bill payments (debit card), home assistance services (repairs).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve neuropsychological testing with an out-of-network
provider.

You asked the Plan to pre-approve the testing. The Plan denied your request. The Plan says the services are
available 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 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
neuropsychological testing with an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power mobility device (E1399).
You asked the Plan to pre-approve the power mobility device. You say that the enrollee's previous mobility device is in disrepair and they need the mobility device. The Plan denied your request. The Plan says there was no prescription order for the scooter, there was no home assessment done.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The file shows that there was not a detailed written order for the billed code. There was no home assessment done to confirm necessity. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a power mobility device (E1399).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the periodic oral evaluation, prophylaxis, intraoral x-ray and unspecified preventive procedure provided on January 14, 2021 and the limited oral evaluation and unspecified preventive procedure provided on February 26, 2021.
You asked the Plan to pay more for the periodic oral evaluation, prophylaxis, intraoral x-ray, unspecified preventive procedures and limited oral evaluation. You say that you have an ongoing dental issue and feel this should be covered. You say that they were not billing insurance correctly and payment should be due. The Plan denied your request. The Plan says the claims processed correctly.
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, your contract says that you pay 50% coinsurance for each cleaning and 50% coinsurance for each routine oral exam from an out-of-network provider. The intraoral x-ray, unspecified preventive procedure and limited oral evaluation are not covered benefits. Therefore, we decided that the Plan does not have to pay more for the periodic oral evaluation, prophylaxis, intraoral x-ray and unspecified preventive procedure provided on January 14, 2021 and the limited oral evaluation and unspecified preventive procedure provided on February 26, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81404, 81405, 81407, 81408) provided February 3, 2021.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services billed.
The Plan must follow Medicare rules. Medicare rules say that all diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary We looked at the file and Medicare rules. The plan has confirmed with the treating physician that the test at issue was not ordered. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (81404, 81405, 81407, 81408) provided February 3, 2021.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve evaluation and treatment to be provided by an out-of-network provider.
You asked the Plan to pre-approve evaluation and treatment with an out-of-network provider. You say that you need to be treated at this facility because this is the only hospital that can provide the needed services. The Plan denied your request. The Plan says that this provider is out-of-network with the Plan and you can be treated by an in-network provider.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not specify any in-network provider that is capable of meeting the standards of care required for treatment of your condition. Without this information, we cannot determine whether you can be treated by an in-network provider. The Plan does not dispute the medical necessity of your treatment, only the network status of the requested provider. Therefore, the Plan has not shown that their decision to deny authorization on the basis of a network lock-in is medically correct or justified according to Medicare rules and your contract with the Plan. Therefore, we decided that the Plan has to pre-approve evaluation and treatment 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 spherocylinder bifocal lenses (V2203) and lens tint (V2745) provided on March 24, 2021.

You asked the Plan to pay for spherocylinder bifocal lenses and lens tint. You say that you would like a review of your claim and reconsideration of payment on this claim. The Plan denied your request. The Plan says you exhausted your benefit, and you are responsible for the remaining balance.

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 contract says you have a $150 allowance once per year to use towards the purchase of eyeglasses or contact lenses.

We looked at the file and the Plan's rules. The records show you exhausted your $150 maximum allowed benefit on March 24, 2021. The records also show that you purchased frames at an allowed amount of $114, sphere bifocal lenses at an allowed amount of $29.50 and spherocylinder bifocal lenses at an allowed amount of $6.50. You received the total allowed amount of $150 ($114 + $29.50 + $6.50 = $150). Based on this information, we decided that the Plan's rules for coverage of spherocylinder bifocal glasses and a lens tint have not been met. Therefore, we decided that the Plan does not have to pay for spherocylinder bifocal lenses (V2203) and lens tint (V2745) provided on March 24, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion spacer.
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 enrollee has lumbar spinal stenosis. The requested Vertiflex Superion spacer is considered experimental/investigational in nature, as more research is needed to show safety and efficacy. The services are therefore not reasonable or medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion spacer.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC).
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. The rules say that for equipment to be covered, it must be appropriate
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.
Records show that these services are being requested for use in a SNF or hospital. Therefore, we decided that
the Plan does not have to pre-approve a Group 3 power wheelchair (PWC).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bed side rails, half length (E0305).
You asked the Plan to pre-approve bed rails. You say that you have arthritis, and it is hard to sit up and for you
to get out of bed. The Plan denied your request. The Plan says this item is not covered as the you do not have a
hospital bed and the requested bed rails is for your personal bed.
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 bed rails have not been met. Therefore, we decided that the Plan does not have to pre-approve a
bed side rails, half length (E0305).
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 are pre-diabetic and your doctor said you should get these orthotics. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation system.
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. The rules say that a power seat elevation feature (E2300) and power standing feature (E2301) are non-covered. We looked at the file and Medicare rules. The requested power seat elevation system is denied by Medicare as non-covered. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on February 1, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the physician services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not emergent or pre-authorized. There were network providers 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 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 pay for these items/services. Therefore, we decided that the Plan does not have to pay for physician services provided on February 1, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a debridement (11042) provided January 15, 2021.
You asked the Plan to pay for the debridement. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the claim 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.
We find that CPT code 11042 is not supported in the medical record. Specifically, the claim was billed with modifier 79, however there was no operative service provided prior to the service billed. Based on this information, we decided that Medicare rules for coverage of the debridement have not been met. Therefore, we decided that the Plan does not have to pay for a debridement (11042) provided January 15, 2021.