Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to reduce the cost for the test materials. We decided that the Plan does not have to
waive the cost for the test materials.

You asked the Plan to waive the cost for the test materials. You say that you are being charged for office visits
which is not right. You say that these are home tests. The Plan says that the copayments applied correctly.

We decided that the Plan has to waive the cost for the test materials.

The provision of test materials from a supplier is not considered a physician service. The test materials are
considered medical supplies which have 20% coinsurance per your contract with the Plan. This means the Plan
has to reduce the cost from $35 per date of service for the test materials to 20% per date of service for the test
materials.

We also decided that the Plan does not have to waive the cost for the test materials.

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 20%
coinsurance for medical supplies. Therefore, we decided that the Plan does not have to waive the cost for the
test materials.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a four-wheeled walker (E0143).

You asked the Plan to pre-approve a four-wheeled walker. You say that the requested item is a medical necessity for you. The Plan denied your request. The Plan says the requested item is not reasonable and necessary.

The Plan follows Medicare rules. The rules say that a standard walker and related accessories are covered if all of the criteria listed in the Medicare rules section are 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 a four-wheeled walker. Our reviewer says that the requested item is not medically necessary. Our physician reviewer found that you were provided with a folding front wheel walker that meets your needs. Safety is a concern with a four-wheeled walker because a four-wheeled walker rolls significantly faster than the front-wheel walker that you are accustomed to. You are scheduled for evaluation and safety of a four-wheeled walker. You do not meet the Medicare criteria for a four-wheeled walker at this time.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a four-wheeled walker have not been met. Therefore, we decided that the Plan does not have to pre-approve a four-wheeled walker (E0143).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that your medical needs are being met in the current acute setting.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. You are receiving appropriate care at the present acute care hospital. You do not require services at the LTACH that are not available at the acute care hospital where you are currently receiving care. Our physician reviewer found that your condition does not meet Medicare criteria for LTACH services. 

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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for Part B prescription drugs purchased on January 4, 2021.
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 there was a contract provider 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 Part B prescription drugs purchased on January 4,
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on September 8, 2020.

You asked the Plan to pay for office visit. You say that you are appealing with supporting records. The Plan
denied your request. The Plan says the denial of payment for this service is correct, because this provider is
out-of-network with the Plan and authorization was not obtained.

Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and
pre-approved care.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for office visit. Our reviewer says that this
service does not meet the Medicare criteria for urgent out-of-area care. Our physician reviewer found the
enrollee could have foreseen the need for this service prior to leaving the Plan's service area. The records do
indicate that this visit was medically necessary. However, it would have been medically reasonable to delay the
service until the enrollee returned to the Plan's service area or up to 6 months.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of office visit have not been met. Therefore, we decided that the Plan does not
have to pay for an office visit provided on September 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for 2 core build up (D2950), 2 retainer crowns (D6750), and 2
pontics (D6240) provided on January 5, 2021.

You asked the Plan to pay for the dental services. You say that you enrolled in the optional dental rider in
November 2020. You say that you were informed that it would roll over to 2021 until you cancel it. You say
that your wife called the plan in December 2020 and January 2021 to verify the status of your dental coverage.
You say that you were assured the coverage was in effect and received a bill to reflect that. You say that now
the plan says there was a miscommunication, and that the coverage was terminated. You also say that you have
been signed up again and coverage will be effective in February 2021. The Plan denied your request. The Plan
says you were not enrolled in the optional dental rider on the date of service in this case.

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 were not enrolled in the optional
dental rider at the time you received these services. The record shows that you switched plans as of January 1,
2021, therefore, the optional dental rider did not transfer into 2021. Therefore, we decided that the Plan does
not have to pay for 2 core build up (D2950), 2 retainer crowns (D6750), and 2 pontics (D6240) provided on
January 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia provided by an out-of-network provider on January 4, 2021.

You asked the Plan to pay for the anesthesia. You say that the facility and/or surgeon participate with the Plan. You say that the claim should be processed at the in-network benefit level. The Plan denied your request. The Plan says this provider is not a network provider 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 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 the anesthesia provided by an out-of-network provider on January 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a custom fabricated abutment (D6057 x 2), an Overdenture (D5865), and a surgical placement of implant body (D6010 x 2).

You asked the Plan to pre-approve the dental services. You say that you need coverage for these services. You say that implants are your only option. You say that you cannot chew. You also say that you cannot get with any dentist because implants are not covered. The Plan denied your request. The Plan says custom fabricated abutment is not listed as a covered service. The Plan says that Overdenture is not listed as a covered service. The Plan also says that surgical placement of implant body is not listed as a covered service either.

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 custom fabricated abutment (D6057 x 2), an Overdenture (D5865), and a surgical placement of implant body (D6010 x 2).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for SNF services provided from March 4, 2020, through
April 2, 2020.

You asked the Plan to pay for the SNF services. The Plan denied your request. The Plan says the SNF services were not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that from a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. His appetite was good. He was treated for a skin tear. He used oxygen via nasal cannula. He received a brief course of IV fluids. Regarding rehabilitation services, the enrollee received physical therapy (PT) and occupational therapy (OT) evaluations and then speech therapy (ST) in the SNF at a non-skilled level. By the dates in question, the enrollee required a mechanical lift for transfers. The enrollee required varying assist with activities of daily living (ADLs). He tolerated a regular diet and thin liquids by discharge from ST. There are identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. As a practical matter, the enrollee does 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pay for SNF services provided from March 4, 2020, through April 2, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eight (8) additional PT visits.

You asked the Plan to pre-approve the eight (8) additional PT visits. The Plan denied your request. The Plan says eight (8) additional PT visits are not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.

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 eight (8) additional PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the additional therapy is not generally accepted as specific and effective therapy for your condition beyond what was approved by the health Plan. You have had prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or for physical therapy, by or under the supervision of a therapist. You have been instructed in and you are participating in a home exercise program. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration.

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 eight (8) additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve eight (8) additional PT visits.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain
rendered on January 22, 2021.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says procedure code 70450 is not covered.

The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically
appropriate NCCI modifier is used to report the reason it should be paid as well.

The provider submitted a claim for procedure codes 70450 and 70496. Code 70450 is a column II code with a
modifier indicator of 1 when billed with column I code 70496. Code 70450 was not billed with an appropriate
modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the
computed tomography (CT) scan of the head/brain rendered on January 22, 2021.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay for the comprehensive oral evaluation. We decided that the Plan does not
have to pay for the 2D oral/facial photographic image.

You asked the Plan to pay for the 2D oral/facial photographic image and comprehensive oral evaluation. You
say that you believe these services should be covered. The Plan says that the 2D oral/facial photograph
(D0350) is not a listed covered benefit. The Plan also says that the maximum allowance has been met for the
comprehensive oral evaluation.

We decided that the Plan has to pay for the comprehensive oral evaluation (D0150).

The Plan follows Medicare rules. Medicare rules say that Medicare plans must make reasonable and diligent
efforts to gather and forward information to the IRE.

The dental directory says that one of either codes D0120, D0140, D0150, D0160, D0170, D0171, or D0180 is
allowed once every 6 months. The documentation does not show that you had received another oral evaluation
within 6 months of the date of service at appeal. Therefore, we decided that the Plan has to pay for the
comprehensive oral evaluation (D0150).

We also decided that the Plan does not have to pay for the 2D oral/facial photographic image (D0350).

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 pay for the 2D
oral/facial photographic image (D0350).

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Onyx OCR video magnifier with speech (V2799).

You asked the Plan to pre-approve an Onyx OCR video magnifier with speech. You say that the service requested is medically necessary. The Plan denied your request. The Plan says the service is not a covered benefit.

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. 

We looked at the file and the Plan's rules. Though the Plan offers a vision 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 an Onyx OCR video magnifier with speech (V2799).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a Superion interspinous stabilization device (22869).

You asked the Plan to pre-approve this service. You say that this service is medically necessary. The Plan denied your request. The Plan says this service 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.

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 this service. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found that current evidence based medical guideline and peer reviewed literature do not fully support the spinal decompression device procedure over the 'gold standard' of lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for your medical condition. The Food and Drug Administration (FDA) indications include implantation of the Superion device at one or two adjacent lumbar levels in patients with moderate spinal stenosis in whom operative treatment is indicated at no more than two levels, from L1 to L5. Formal imaging studies have not been provided for review.

You have been noted to have multiple degrees of spinal stenosis, many not at FDA indicated levels of "moderate" spinal stenosis (including the planned operative level). FDA contraindications include spinal instability, scoliosis, obesity, and osteoporosis, which have not been adequately addressed in the medical records.

There is noted imaging evidence of retrolisthesis with no discussion of spinal instability on flexion/extension films. Imaging studies are not provided and there is no discussion regarding scoliosis and/or documentation of the Cobb angle. There is no discussion indicating that a dual-energy x-ray absorptiometry (DEXA) scan has demonstrated a lack of significant osteoporosis. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of a Superion interspinous stabilization device (22869).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical placement of implant body: endosteal implant (D6010) provided February 12, 2021.
You asked the Plan to pay for the endosteal implant. You say that you would like the implant covered. The Plan denied your request. The Plan says this type of implant is not covered under your dental 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, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the surgical placement of implant body: endosteal implant (D6010) provided February 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.

You asked the Plan to pre-approve IRF care. You say that IRF services are medically necessary. The Plan
denied your request. The Plan says coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.

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 IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found there is not a reasonable expectation that the enrollee will be able to fully participate
in and benefit from the intensive rehabilitation therapy program provided in an IRF. There are no complex
nursing or rehabilitation needs. The enrollee's needs can be met at a lower level of care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.