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

We decided that the Plan does not have to pre-approvedenial is for crown-porcelain/ceramic substrate, tooth 18 (D2740).You asked the Plan to pre-approvethe crown. You say that the records should support the necessity of the service in dispute.The Plan denied your request. The Plan says the records do not support medical necessity of this request.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 crown when the services are medically necessary and reasonable. We asked our physician reviewer to carefullyreview the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the crown. Our reviewer says that this enrollee does not meet the criteria for the requested crown. Our physician reviewer found at present it has not been shown that the structure is insufficiently damaged to qualify for a crown, and the furcation involvement reduces the long term prognosis.  Given the lack of overall damaged structure, the appearance of the craze/crack line and the furcation involvement, there appears to be no necessity found for a crown placement.  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 crown havenot been met.Therefore, we decided that the Plan does not have to pre-approvedenial is for crown-porcelain/ceramic substrate, tooth 18 (D2740).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medical services to be provided by an out-of-network
provider.
You asked the Plan to pre-approve the services. 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 medical
services to be provided by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided to the enrollee on October 28,
2019.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the place of service
on the claim form must reflect the location when the specimen was obtained.
The Plan must follow Medicare rules. Medicare rules say that the place where the sample was taken is reported
as the Place of Service (POS).
We looked at the file and the Medicare rules. The claim shows the place of service as an independent
laboratory. The records provided do not show that the specimen was collected at an independent lab. Based on
this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that
the Plan does not have to pay for the lab services provided to the enrollee on October 28, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the enteral formula, Glucerna (B4152).
You asked the Plan to pre-approve the enteral formula. You say that you are appealing the denial for coverage because you are in need of the nutritional supplement but you cannot afford to buy it. The Plan denied your request. The Plan says the enrollee does not meet the criteria and this request is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules say that Medicare does not pay for nutritional supplementation. 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 enteral formula. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no evidence that the enrollee is unable to sustain herself through her regular oral intake. The enrollee has been referred to a nutritionist and standard dietary recommendations have been provided. There is no indication on a medical basis for prescribing Glucerna. The request 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 the enteral formula have not been met. Therefore, we decided that the Plan does not have to pre-approve the enteral formula, Glucerna (B4152).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveupgraded electronics electronic connection (E2311) expandable controller (E2377) and expandable controller harness (E2313).You asked the Plan to pre-approvethe upgraded electronics. You say that the request for the equipment is not for her convenience but a medical necessity.The Plan denied your request. The Plan says there is no medical need to control the requested power options through the joystick.The Plan must follow Medicare rules. Medicare rulessay 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 upgraded electronics. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no indication a wheelchair could not be safely, and adequately utilized without these accessories. This is a convenience item and as such, this request is not 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 the upgraded electronics have not been met.Therefore, we decided that the Plan does not have to pre-approveupgraded electronics electronic connection (E2311) expandable controller (E2377) and expandable controller harness (E2313).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services with an out of network dental provider.
You asked the Plan to pre-approve the out of network dental services. You say that the out of network provider
is the only dentist who is able to accommodate the enrollee's special needs. The Plan denied your request. The
Plan says there are dentists in your area who can provide the care needed.
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 covered services are limited to
those supplied by a participating provider. The provider you are requesting these services through is not
contracted with the Plan. Therefore, the services being requested are non-covered. Therefore, we decided that
the Plan does not have to pre-approve dental services with an out of network dental provider.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for a positron emission tomography (PET) with concurrently acquired computed tomography (CT) scan from skull base to mid-thigh (78815-26-PS) provided on November 20, 2019.
You asked the Plan to pay for a PET CT scan from skull base to mid-thigh. You say that the service was denied as a duplicate in error. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that a different cancer diagnosis whether submitted with a PI or a PS modifier will begin the count of one initial and three subsequent FDG PET scans not requiring the KX modifier. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a PET CT scan from skull base to mid-thigh have been met. Specifically, the record shows that the provider billed the 4th PET scan as 78815-26-PS. The 4th PET scan was billed with a different cancer diagnosis code than the other three. This means that the KX modifier is not required in this case, as the count of one initial and three subsequent FDG PET scans is restarted in this circumstance. Therefore, we decided that the Plan has to pay for a positron emission tomography (PET) with concurrently acquired computed tomography (CT) scan from skull base to mid-thigh (78815-26-PS) provided on November 20, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the pneumatic compressor and appliances provided on
October 15, 2019.
You asked the Plan to pay for the pneumatic compressor and appliances. You say that the Plan should pay this
claim. The Plan denied your request. The Plan says the documentation submitted did not include an itemized
shipping/billing invoice to indicate the specific supplies or proof of deliver for the billed date of service.
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 record shows that the Plan made several attempts to obtain the proof of delivery documentation for the
items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in
this case. There is no delivery ticket or proof of delivery. Therefore, we decided that the Plan does not have to
pay for the pneumatic compressor and appliances provided on October 15, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay forthe train of four testing provided to the enrollee on September 25, 2019.You asked the Plan to pay forthe testing services. You say that intraoperative neuromonitoring was necessary per the ordering physician.The Plan denied your request. The Plan says the cost is included in the cost of the primary procedure.The Plan must follow Medicare rules. Medicare rules say that all services integral to accomplishing a procedure are considered bundled into that procedure.The file shows that the enrollee received train of four testing during neuromonitoring services. The records provided shows that the TOF testing was performed to verify the validity of the monitoring procedure. It is inappropriate to separately report these services. Therefore, we decided that the Plan does not have to pay forthe train of four testing provided to the enrollee on September 25, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on September 16, 2019.
You asked the Plan to pay for drug test. You say that you are appealing with attached requisition form. The Plan denied your request. The Plan says the denial of payment for this service is correct, because the documentation submitted did not include a valid physician order, lab requisition, or medical records to verify the billed code.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted did not include a valid physician order or clear intent to order the specific lab services billed on this claim. Based on this information, we decided that Medicare rules for coverage of drug test have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided by on September 16, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the abdomen (74183) and 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision (76376).

You asked the Plan to pre-approve an MRI of the abdomen and 3D rendering with interpretation and reporting. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.

The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 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 an MRI of the abdomen and 3D rendering with interpretation and reporting. Our reviewer says that the services are not medically necessary. Our physician reviewer found you have no clinical jaundice but do reportedly have elevated alkaline phosphatase. Liver function studies are not included in the records. Conventional imaging of the biliary system, pancreas and liver was normal. The solitary elevation of alkaline phosphatase in a non-jaundiced enrollee without supporting documentation of other abnormal liver enzymes does not seem a reasonable indication for magnetic resonance cholangiopancreatography (MRCP) especially given the normal sized common duct and normal pancreas.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an MRI of the abdomen and 3D rendering with interpretation and reporting have not been met. Therefore, we decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the abdomen (74183) and 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision (76376).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 9, 2019 to August
24, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. You say that the services provided were reasonable and
medically necessary. The Plan denied your request. The Plan says the enrollee has no out-of-network benefits.
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 services at issue in this appeal. The Plan did not pre-approve the services at
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that
the Plan does not have to pay for the medical services provided on August 9, 2019 to August 24, 2019 by an
out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a raised toilet seat.
You asked the Plan to pre-approve a raised toilet seat. You say that you are unable to use your right arm to get up from the toilet seat. 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 raised toilet seats are not covered because they are not primarily medical in nature. While a raised toilet seat may be appropriate for the enrollee, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a raised toilet seat.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forPT provided from June 18, 2019 to July 29, 2019.You asked the Plan to waive the copayments forPT. You say that you were never told that you would owe a $40 copayment.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $40 copayment for outpatient rehabilitation services. You received PT from June 18, 2019 to July 29, 2019 for a total of 13 visits. Therefore, you are responsible to pay a $40 copayment per each visit. The total amount you owe is: $40 (copayment) x 13 (PT visits) = $520.You have been asked to pay the total copayment amount of $520 for PT. PT falls within the outpatient rehabilitation services 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 copayments forPT provided from June 18, 2019 to July 29, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea non-preferred continuous glucose monitor.You asked the Plan to pre-approvethe requested device. The Plan denied your request. The Plan says there is no documentation that specifies why a non-preferred device must be used.Medicare rules say that plans can require enrollees to get care from network providers. The rules say that a MA plans may specify brands and manufacturers as preferred.The requested CGM is not a preferred device with the plan. The Plan has specific brands for the item at issue in this appeal. We found no exception that would require the Plan to pre-approve the requested item. Therefore, we decided that the Plan does not have to pre-approvea non-preferred continuous glucose monitor.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for wound care services provided on November 27, 2019 by an
out of network (OON) provider.
You asked the Plan to pay for the out of network wound care services. You say that the services were provided
while the enrollee was in the nursing home. You say that the services were provided prior to obtaining
authorization in order to prevent delay in care. The Plan denied your request. The Plan says there were
contracted providers who could have supplied the wound care needed. The Plan says that the records indicate
that this was not an emergency and there was no authorization on file.
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 for wound care services provided on November 27,
2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveoffice visits (99212), duplex scans (93971), and ablation therapy (36478) to be provided by an out of network (OON) provider.You asked the Plan to pre-approveOON office visits, duplex scans, and ablation therapy. You say that these services are medically necessary.The Plan denied your request. The Plan says these services are available from in-network providers.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-approveoffice visits (99212), duplex scans (93971), and ablation therapy (36478) to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe panoramic x-ray (D0330) provided on November 7, 2019.You asked the Plan to pay forthe dental service. You say that your dentist referred you to this provider because you have heart failure and are on a blood thinner.The Plan denied your request. The Plan says the provider in this case is not your assigned dental provider, nor is it a plan provider. The Plan says the services were not authorized. The Plan also says the service was not urgent or emergent.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 panoramic x-ray is only covered when you receive this service from your assigned dental facility. The record shows that you were advised prior to receiving the x-ray that it would not be covered, but a discount would be provided.Therefore, we decided that the Plan does not have to pay forthe panoramic x-ray (D0330) provided on November 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested ophthalmology services.
You asked the Plan to pre-approve the ophthalmology services. You say that when you were going through
enrollment with the Plan, you were told this provider was in-network. The Plan denied your request. The Plan
says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis
while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider,
which requires prior authorization from 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 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 the
requested ophthalmology services.