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

We decided that the Plan does not have to pay forintraoral X-rays (D0210) received on March 6, 2020.You asked the Plan to pay forintraoral X-rays. You say that you are upset with your provider as these services were rendered when the benefit was exhausted.The Plan denied your request. The Plan says rules for payment have not been met.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 full mouth X-rays once every 36 months. We looked at the case file and Medicare rules. The record shows that you previously received a full mouth X-ray on January 29, 2019. It has not been 36 months since your previous full mouth X-ray. Based on this information, we decided that the Plan's rules for coverage of intraoral X-rays have not been met.Therefore, we decided that the Plan does not have to pay forintraoral X-rays (D0210) received on March 6, 2020.Your complaint about receiving services for which the benefit has been exhausted from your provideris not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed (CPT Code E0260, ten (10)
month rental).
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your
request. The Plan says the Medicare rules have not been met. The Plan must follow Medicare rules. We looked
at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the
DME have not been met. While the supplied documentation may support a fixed height or even a variable
height hospital bed, it does not support the coverage criteria for a semi-electric hospital bed. To meet criteria
for a semi-electric hospital bed the member must need frequent and/or immediate changes in position.
Furthermore, if the member qualifies for a hospital bed, both the fixed height and variable height allow for
elevation of the head and foot of the bed with only the control mechanisms differing from the semi-electric bed.
This request has been denied as the LCD criteria have not been met for a semi-electric hospital bed. Therefore,
we decided that the Plan does not have to pre-approve a semi-electric hospital bed (CPT Code E0260, ten (10)
month rental).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forshoulder elbow wrist hand orthosis (L3960) provided on August 7, 2020.You asked the Plan to pay forthe orthosis. You say that you would like reconsideration because this equipment was medically necessary.The Plan denied your request. The Plan says the delivery ticket did not include the carrier's tracking number and the proof of delivery is not itemized to indicate the specific supplies.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The recorddoes not contain a valid proof of delivery for the supplies provided in this case. Specifically, the proof of delivery did not include an itemized billing/shipping invoice to verify the billed supplies. The record shows that the Plan made several attemptsto obtain the necessary documentation without success.Therefore, we decided that the Plan does not have to pay forshoulder elbow wrist hand orthosis (L3960) provided on August 7, 2020
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forlaboratory services (87150, 87482, 87500, 87640, 87653, 87798, 87799, 81001) provided on August 24, 2020.You asked the Plan to pay forlaboratory services. You say that these services were performed.The Plan denied your request. The Plan says there is not enough information to show these services were medically necessary.The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.We looked at the file and Medicare rules. The submitted documents do not include a physician order for the tests at issue or medical records demonstrating the medical need for these tests. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met.Therefore, we decided that the Plan doesnot have to pay forlaboratory services (87150, 87482, 87500, 87640, 87653, 87798, 87799, 81001) provided on August 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean office visit to be provided by an out of network (OON) provider.You asked the Plan to pre-approvean office visit. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services can be provided by a network provider.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-approvean office visit to be provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveprolia60 mg/ml syringe (J0897).You asked the Plan to pre-approveprolia. You say that the service is medically necessary.The Plan denied your request. The Plan says for a Medicare Advantage & Part D drug plan (MAPD) like yours, Part D can cover when:the pharmacy dispenses the drug to you to self-administer, or to take it to your provider; or is given in a long term care facility (LTC); or is given in your home, or in assisted living-without an infusion pump. Part B covers in all other circumstances.The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage.Therefore, we decided that the Plan does not have to pre-approveprolia 60 mg/ml syringe (J0897).Benefits for proliamay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a MyoCycle home functional electrical stimulation
cycling therapy system for the enrollee.
You asked the Plan to pre-approve a MyoCycle. You say that this is medically necessary. The Plan denied your
request. The Plan says your request is not medically necessary because records show the enrollee does not have
muscle atrophy or difficulty walking due to a spinal cord injury.
The Plan must follow Medicare rules. Medicare rules say that FES is covered for the above indications.
We looked at the file and Medicare rules. The file does not indicate the enrollee is using this to treat nonneurological
muscle atrophy or has a spinal cord injury. Based on this information, we decided that Medicare
rules for coverage of a MyoCycle have not been met. Therefore, we decided that the Plan does not have to preapprove
a MyoCycle home functional electrical stimulation cycling therapy system for the enrollee.
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 bilateral orthotics for heel pain. 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a barium esophagram be provided at a hospital-based
facility.
You asked the Plan to pre-approve the barium esophagram from a hospital-based facility. You say that you
cannot drive far and do not want to use the Plan's transportation services due to COVID-19. The Plan denied
your request. The Plan says it is not medically necessary to receive the barium esophagram at the facility being
requested.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered. Medicare rules also say that information must be submitted to confirm that Medicare
criteria for coverage have been met. Medicare rules say that plans must make care accessible to enrollees.
According to Medicare rules, care is considered accessible to an enrollee if contract providers are available
within reasonable distance and travel time from the enrollee's home.
We looked at the file and Medicare rules. We found no argument or evidence that it is medically necessary for
the enrollee to receive the approved services at a hospital-based facility. The case file shows that the Plan
approved coverage of a barium esophagram with different in network facilities that are within a reasonable
distance and travel time from the enrollee's home. Based on this information, we decided that Medicare rules
for coverage of the barium esophagram from a hospital-based facility have not been met. Therefore, we
decided that the Plan does not have to pre-approve a barium esophagram be provided at a hospital-based
facility.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forout of network physician services provided on July 6, 2020.You asked the Plan to pay forthis visit. You say that this office visit should be covered by the Plan.The Plan denied your request. The Plan says you did not have prior authorization for out of network care.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 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 forout of network physician services provided on July 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approveimplant supported crowns (D6065) for teeth # 19 and 20.You asked the Plan to pre-approvethe dental services. You say that crowns are partially covered by your plan. You say that the requested crowns should be coveredthe same as any other crowns. You say that you understand implants are not covered but you did not just elect to do this. You say that you do not have any other options. You also say that you are only asking coverage for the crowns which are necessary to restore the implants.The Plan denied your request. The Plan says implant supported crowns are not listed as covered services.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.The Evidence of Coverage clearly states that any services not listed are not covered. Therefore, we decided that the Plan does not have to pre-approveimplant supported crowns (D6065) for teeth # 19 and 20.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on February 20, 2020 by an out of network (OON) provider.You asked the Plan to pay forlaboratory testing. You say that your facility does not accept walk-ins and does not have any access to the enrollee's insurance requirements, limitations, or conditions.The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this provider is out-of-network with the Plan and the ordering provider is also out-of-network with the Plan.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 medical services provided on February 20, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvescaling and root planing(D4341).You asked the Plan to pre-approvescaling and root planing. You say that the service is medically necessary.The Plan denied your request. The Plan says the radiographs and notes submitted do not show bone loss or tartar buildup on the root surfaces of at least four teeth to support the need for periodontal scaling instead of a regular cleaning.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 scaling and root planing 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 scaling and root planing. Our reviewer says that the service is not medically necessary. Our physician reviewer found the provided x-rays do not show any appreciable bone loss on teeth #4,5 or 6 which are seen on the provided x-rays. The requested code is reserved where there are four or more involved teeth in any one quadrant. Even if there were bone loss around tooth #4 where the 4 mm pocket was noted, there would be insufficient teeth involved to support the requested code. Given the lack of any noted bone loss, as well as the number of possible involved teeth, there is no medical necessity for the requested procedure under D4341.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 scaling and root planing have not been met.Therefore, we decided that the Plan does not have to pre-approvescaling and root planing (D4341)
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveTramadol.You asked the Plan to pre-approveTramadol. You say that the medication is necessary.The Plan denied your request. The Plan says the enrollee does not have a Medicare Part D benefit or separate pharmacy benefit managed by the plan. Therefore, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types whichare covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approveTramadol.Benefits for Tramadolmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a facet joint injection.
You asked the Plan to pre-approve facet joint injection. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the enrollee does not meet the Medicare criteria for this procedure.
The Plan follows Medicare rules. Medicare rules state that facet joint interventions are only covered when all of the above criteria have 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 facet joint injection. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested facet joint interventions. Our physician reviewer found there was no documentation provided showing that the enrollee had a physical examination performed. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of facet joint injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a facet joint injection.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forsurgical services (CPT 21935) provided to the enrollee on June 3, 2020.You asked the Plan to pay forthe services. You say that this should be paidfor.The Plan denied your request. The Plan says this procedure is rarely or never performed in the non-facility setting.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 21935 is "radical resection of tumor (e.g., sarcoma), soft tissue of back or flank; less than 5 cm."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 documentation submitted does not include an appropriate Place of Service. Place of Service Codes are two-digit codes placed on health care professional claims to indicate the setting in which a service was provided. The Centers for Medicare & Medicaid Services (CMS) maintain POS codes used throughout the health care industry.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 forsurgical services (CPT 21935) provided to the enrollee on June 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pneumatic compressor, segmental home model with
calibrated gradient pressure (CPT Code E0652) and segmental pneumatic appliance for use with pneumatic
compressor, full leg (E0667).
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your
request. The Plan says the DME is not necessary.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the DME. Our physician reviewer
found there was no objective evidence of the truncal edema. A segmental pneumatic compressor and associated
appliance was requested (E0652, E0667). Based on the lack of objective evidence of truncal edema to justify
this request, the LCD criteria is not met for the above device.
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 DME have not been met. Therefore, we decided that the Plan does not have
to pre-approve pneumatic compressor, segmental home model with calibrated gradient pressure (CPT Code
E0652) and segmental pneumatic appliance for use with pneumatic compressor, full leg (E0667).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvefacet injection with synovial cyst aspiration.You asked the Plan to pre-approveInjection(s), diagnosticor therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level (64493). You say that you would like to attempt a block at this level and drain the cyst to relieve the enrollee's low back pain.The Plan denied your request. The Plan says there is insufficient evidence as to necessity.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 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level (64493). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, there is insufficient evidence for a diagnostic facet block at the right L5-S1 level. Theenrollee has already had the facet diagnostic blocks at the same level in the past without relief. In addition, there is insufficient scientific data as to the necessity of aspiration of synovial cysts with facet joints.There is insufficient data to support that it provides lasting pain relief. The review has determined that the requested facet Injection right L5-S1 with synovial cyst aspiration is not medically reasonable or 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 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level (64493) have not been met.Therefore, we decided that the Plan does not have to pre-approvefacet injection with synovial cyst aspiration