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

We decided that the Plan does not have to pay forthe injections (64447 and 64450) provided on March 30, 2018 by an out of network (OON) provider.You asked the Plan to pay forinjections. You say that these services are covered for post-operative pain management.The Plan denied your request. The Plan says these services were not authorized.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 theitem/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 injections (64447 and 64450) provided on March 30, 2018 by an out of network (OON) provider
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 Planto pre-approve IRF care. You say that it is felt that this enrollee would benefit from IRF care.The Plandenied your request. The Plan says the criteria for this level of care are not 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 above.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 the complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the patient's medical status requires the intensity of an IRF stay with close physician or nursing supervision. The patient may benefit and participate in additional therapy of PT and OT but the patient does not require this on an intensive rehabilitation facility therapy program level in an IRF.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 Plandoes not haveto pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the specialist office visit provided on October 23, 2019.
You asked the Plan to waive the deductible for the specialist office visit. You say that you should not be responsible for this amount. You say annual wellness visits have a $0 copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 a $600 deductible is applied towards in-network specialist office visits. The specialist office visit you asked the Plan to waive the deductible for falls within the benefit category "Physician/Practitioner services, including doctor's office visits" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $600 combined deductible that applies towards in-network specialist office visits. The record shows you received a specialist office visit.
This cost sharing is a contractual obligation that had not been met at the time the specialist office visit was received on October 23, 2019. Therefore, we decided that the Plan does not have to waive the deductible for the specialist office visit provided on October 23, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ambulance transport provided by on November 16, 2019.You asked the Plan to waive the copayment forthe ambulance transport. You say that the transport was only a mile from your home. You say that you disagree with your copayment.The Plan denied your request. The Plan says the copayment applied correctly.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 $150 copayment for Medicare-covered one-way ground ambulance benefit.You have been asked to pay a $150 copayment for the ambulance transport. The ambulance transport falls within the "Ambulance services" benefit category. The records show that you were transported by ambulance to the hospital. 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 nothave to waive the copayment forthe ambulance transport provided by on November 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not have to pre-approve the Vertiflex interspinous spacer.You asked the Planto pre-approvethe spacer. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is not medically necessary.The Plan must follow Medicare rules. Medicare rules say that items and services thatare not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the spacer. Our reviewer saysthat the requested spacer is not considered medically reasonable and necessary in this case. Our physician reviewer found this is still considered an experimental and investigational procedure at this point. Also, the published literature evaluates a single level procedure not 2 levels. The requested procedure 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 spacer have not been met.Therefore, we decided that the Plandoes not haveto pre-approvethe Vertiflex interspinous spacer.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea mandibular partial denture (D5214).You asked the Plan to pre-approvethe mandibular partial denture. You say that the enrollee is having trouble with eating and chewing his food. You also say that the partial is needed to restore occlusion.The Plan denied your request. The Plan says this service is not covered under the enrollee's benefit package.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-approvea mandibular partial denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the consultation and dental extraction to be performed by an oral surgeon.You asked the Planto pre-approve the oral surgeon services. You say that you are in extreme pain and need this to be done by an oral surgeon.The Plan denied your request. The Plan says your dental plan does not cover services provided by an oral surgeon.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 dentalbenefit in excess of Medicare coverage, this does not include coverage of the services of an oral surgeon.Therefore, we decided that the Plandoes not have to pre-approve the consultation and dental extraction to be performed by an oral surgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the topical application of fluoride provided on August 12, 2019.
You asked the Plan to pay for the topical application of fluoride. You say that the fluoride treatment is an industry-wide standard at both the six month and one year annual preventive dental cleanings. The Plan denied your request. The Plan says this service is not covered under your plan.
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 topical application of fluoride provided on August 12, 2019.
Your complaint about being misled by the Plan's coverage for 2019 is 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chiropractic treatment.
You asked the Plan to pre-approve the treatment. You say that the expense of treatments is becoming more of a hardship. The Plan denied your request. The Plan says chiropractic care is not medically indicated.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 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 treatment Our reviewer says that the requested treatment is not considered medically reasonable and necessary in this case. Our physician reviewer found Medicare guidelines state that the only service available to chiropractors is to treat a subluxation of the spine. This subluxation may be demonstrated by x-ray or by physical examination. The submitted medical/nurse notes reveal no evidence of a subluxation, but notations regarding pain upon palpation, a positive orthopedic test or two, limited ranges of motion, joint tenderness and normal neurological findings. The submitted chart notes from the chiropractic provider, from August 8, 2019, through January 28, 2020, reveal findings of palpation that reveals subluxations at the cervical, lumbar and thoracic spine, along with the pelvis and muscle spasms of the left and right levator scapulae, left and right rhomboid muscles and left and right erector spinae muscles throughout care. These findings do not reveal a subluxation per Medicare guidelines. Thus, chiropractic treatment is not supported or allowed. 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 treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve chiropractic treatment.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electrical bone growth stimulator.
You asked the Plan to pre-approve an Osteogenesis stimulator. You say that you are concerned there won't be healing without surgical intervention. The Plan denied your request. The Plan says the x-rays show healing.
The Plan must follow Medicare rules. The rules say that an electrical bone growth stimulator is covered for nonunion of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial radiographs have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment with the electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs separated by a minimum of 90 days. In this case, nonunion of a long bone fracture is not considered to exist under Medicare rules. The x-ray findings show healing. Therefore, we decided that the Plan does not have to pre-approve an electrical bone growth stimulator.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approvehome health aide visits.You asked the Plan to pre-approvehome health aide visits. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria hasnot been met.The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or 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 home health aide visits. Our reviewer says that the services are not medically necessary. Our physician reviewer found there is no identified skilled nursing or physical therapy need. When Home Health Aide services are requested and are not in support of a skilled need, the service is not considered 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 home health aide visits have not been met.Therefore, we decided that the Plan does not have to pre-approvehome health aide visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chemotherapy administration (96415) provided on September 20, 2019.
You asked the Plan to pay for chemotherapy administration. You say that this was billed correctly. The Plan denied your request. The Plan says this service is not supported by the records.
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 96415 is chemotherapy administration, intravenous infusion technique; each additional hour (List separately in addition to code for primary procedure). We find that CPT code 96415 is not supported in the medical record. Specifically, this code is for each hour of chemotherapy administration and the medical records do not contain documentation of the time spent on these services. Based on this information, we decided that Medicare rules for coverage of chemotherapy administration have not been met. Therefore, we decided that the Plan does not have to pay for chemotherapy administration (96415) provided on September 20, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgical extraction (D7210) of teeth 24, 25, 26.
You asked the Plan to pre-approve the dental services. You say that the records provided should support the
necessity of the service. The Plan denied your request. The Plan says the requested service does not meet
medical necessity as the documentation submitted does not support the code requested.
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 dental
services when the services are medically necessary and reasonable.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the dental services. Our reviewer says
that the requested service is not medically necessary for this enrollee. Our physician reviewer found in this
instance there is the presence of severe periodontal disease that has caused loss of 50% or more of the
supporting bone around all the teeth in question making for easier removal. There is no clear indication for
surgical removal of the teeth in question as they should be able to be simply removed by elevation and forceps
application, and a lesser code would be more appropriate. Given the clinical appearance of the teeth on x-ray
there is no medical necessity for surgical removal of teeth #24, 25 and 26.
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 dental services have not been met. Therefore, we decided that the Plan does
not have to pre-approve surgical extraction (D7210) of teeth 24, 25, 26.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve Endoscopic Pyloromyotomy.
You asked the Plan to pre-approve the Endoscopic Pyloromyotomy. You say that this service is medically necessary. The Plan denied your request. The Plan says that Endoscopic Pyloromyotomy is unproven in the setting of gastroparesis.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 the Endoscopic Pyloromyotomy. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found having failed both medication and prior surgery, there is no other reasonable intervention option except for this newly applied pyloromytomy procedure. 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 Endoscopic Pyloromyotomy have been met. Therefore, we decided that the Plan has to pre-approve Endoscopic Pyloromyotomy.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve adult day care.You asked the Plan to pre-approvethe services. You say that this is medically necessary.The Plan denied your request. The Plan says adult day care is considered custodial care.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found Medicare does not pay for any items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. The documentation does not support that the requested adult daycare is being furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of your condition or to improve the function of a malformed body member. The progress notes are limited and do not support that adult daycare, which is considered custodial in nature, is medically necessary for your condition.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 services have not been met.Therefore, we decided that the Plan does not have to pre-approveadult day care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper denture (D5110). You asked the Plan to pre-approve a complete upper denture. You say that the item is necessary since you lost your current one. The Plan denied your request. The Plan says the benefit allowance has been exhausted. Therefore, coverage criteria has 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 one complete upper denture once per 60 months. We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a complete upper denture have not been met. Specifically, you received a complete upper denture on November 9, 2017. This means that you are not eligible for health plan coverage of a complete upper denture at this time. Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided on December 9, 2019.
You asked the Plan to pay for the dental service. You say that the Evidence of Coverage (EOC) indicates that cleanings have $0 out of pocket and are covered at 100%. You say that you were not aware that you had reached your annual maximum. You also say that it should be clearly written in the EOC as to what applies to the maximum as it is unclear. The Plan denied your request. The Plan says the annual maximum of $2,500 has been exceeded.
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 annual maximum of $2,500 has been exceeded.
Claim Number
Billed Amount
Allowed Amount
Plan Paid
20190218002262
$227
$111
$111
20190603107897
$306
$136
$136
20190531113909
$3,090
$3,090
$2,253
TOTAL:
$2,500
Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided on December 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for extraspinal chiropractic manipulation (98943) provided on November 5, 2019.
You asked the Plan to pay for extraspinal chiropractic manipulation. You say that these services were necessary to ease your pain. The Plan denied your request. The Plan says this service is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for extraspinal chiropractic manipulation (98943) provided on November 5, 2019.