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

We decided that the Plan does not have to pay more for the two periodontal scalings and root planings, or pay for the localized delivery of antimicrobial agents and two gingival irrigations provided on October 20, 2020 by an OON provider.

You asked the Plan to pay for the localized delivery of antimicrobial agents and gingival irrigations, and pay more for the scalings and planings. You say that you believe these services should be covered in full. The Plan denied your request. The Plan says these services are not covered. The Plan also says that you did not contact the Plan prior to this date of service to verify benefits and provider eligibility.

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 contract also clearly states that you must pay a 50% coinsurance for periodontal scalings and root planings that are received OON. The Plan does not need to pay more than 50% for the scalings and planings. Therefore, we decided that the Plan does not have to pay more for the two periodontal scalings and root planings, or pay for the localized delivery of antimicrobial agents and two gingival irrigations provided on October 20, 2020 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for paring or cutting of benign Hyperkeratosis lesion (e.g., corn
or callus) (11055).

You asked the Plan to pay for paring or cutting of benign Hyperkeratosis lesion. You say that you have been
going to get your nails cut for about 9 years and went to a different doctor. The doctor is now retired, and it has
always been a covered service. The Plan denied your request. The Plan says this service is not a covered
benefit.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of paring or cutting of benign Hyperkeratosis lesion have not been met. Therefore, we decided that the
Plan does not have to pay for paring or cutting of benign Hyperkeratosis lesion (e.g., corn or callus) (11055).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the crown (D2740) and core build up (D2950) for teeth # 20 and 30.

You asked the Plan to pre-approve the dental services. You say that you were in the process of having the crown work completed while you were under your previous insurance. You say that you had temporary crowns installed. You say that if you do not get the crowns that you need, the temporary crowns will fall out and you will need to have the teeth extracted. You also say that you did not know your insurance would not cover this, otherwise you would have changed it. The Plan denied your request. The Plan says crowns are not listed as covered services. The Plan also says core build up 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 the crown (D2740) and core build up (D2950) for teeth # 20 and 30.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).

You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the services can be safely received in other settings, for example: a skilled nursing facility.

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 the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted of weakness and edema after missing outpatient hemodialysis. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided 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 Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on July 22, 2020.

You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were not billed correctly.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

We find that the laboratory services are not supported in the medical record. Specifically, when a laboratory assays two or more genes in an enrollee in parallel, those two or more genes will be considered part of the same panel. These services provided were billed incorrectly. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on July 22, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hepatobiliary system imaging services.

You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the documentation does not indicate a condition for which a Hepatobiliary scan would be 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 the requested services. Our physician reviewer found that the enrollee received an abdominal computed tomography (CT) scan. Pertinent to this review, findings included: evidence of partial sigmoidectomy, multiple hepatic cysts, absence of intrahepatic biliary duct dilation, and absence of detected pancreatic pathology. The gallbladder was distended, and the common duct was somewhat prominent. The requested scan is generally indicated in evaluation of cholecystitis (acute versus chronic), bile duct obstruction, congenital anomalies of the bile ducts, biliary leak, biliary stent patency, and in cases of sphincter of Oddi dysfunction. The enrollee's available record neither support acute elevations in liver function tests, nor symptoms referrable to her right upper abdominal quadrant that may be attributed to the biliary tract. The mere radiologic finding of gallbladder distension (a phenomenon commonly seen during periods between meals and with fasting) is of itself not a medically necessary nor appropriate indication for the requested imaging.

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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve Hepatobiliary system imaging services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a surgical tooth extraction.

You asked the Plan to pre-approve these services. You say that your teeth need to be extracted. The Plan denied your request. The Plan says the request exceeds the benefit limit.

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 up to two simple or surgical extractions per calendar year.

We looked at the file and the Plan's rules. The file shows that you were approved for two tooth extractions. Further extractions are not covered by your supplemental dental benefit or Medicare. The extractions are not covered by your medical benefit because they are not being done to prepare the jaw for radiation treatments. Based on this information, we decided that the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a surgical tooth extraction.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office consultations and treatment to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve the office consultations and treatment. You say that your provider has been treating your ocular melanoma. You say this location has the machine needed for treatment and you do not want to start over with another provider. The Plan denied your request. The Plan says the provider is out of 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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the office consultations and treatment to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a thoracic lumbar sacral orthosis (L0457) provided October 1, 2020.

You asked the Plan to pay for a back brace. You say that this item was medically necessary for the enrollee. The Plan denied your request. The Plan says this service is not covered.

The Plan must follow Medicare rules. Medicare rules say that coverage of durable medical equipment is prohibited if the supplier makes unsolicited contact with the enrollee. 

We looked at the file and Medicare rules. In this case, the Plan has attested that the enrollee was contacted via an unsolicited phone call regarding the provision of the item at issue. Based on this information, we decided that Medicare rules for coverage of a back brace have not been met. Therefore, we decided that the Plan does not have to pay for a thoracic lumbar sacral orthosis (L0457) provided October 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee.

You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says the clinical information does not indicate that the enrollee is on insulin injections three of more times per day.

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 monitor. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is on a single daily does of insulin. The dose is not adjusted frequently based upon the result. The elements of the local coverage determination are not satisfied. The requested service cannot be recommended. 

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 monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve arm pad replacements (K0019) and repair service for durable medical equipment (K0739).

You asked the Plan to pre-approve arm pad replacements and repair service for durable medical equipment. You say that the requested items are needed in order to guarantee ongoing safe mobility for the enrollee. The Plan denied your request. The Plan says rules for repair and replacement are not met because the useful life of the requested items is 5 years.

The Plan must follow Medicare rules. Medicare rules say that, in the absence of program instructions, the reasonable useful lifetime of equipment in no case can be less than 5 years. Computation of the useful lifetime is based on when the equipment is delivered to the enrollee, not the age of the equipment. 

We looked at the file and Medicare rules. In this case, you are requesting replacement components for a power wheelchair received by the enrollee. Therefore, the requested replacements are for items that have not outlasted their reasonable useful lifetime. Based on this information, we decided that Medicare rules for coverage of arm pad replacements and repair service for durable medical equipment have not been met. Therefore, we decided that the Plan does not have to pre-approve arm pad replacements (K0019) and repair service for durable medical equipment (K0739).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).

You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says needs can be safely and effectively met at a lower level of care, such as SNF.

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 the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for right sided weakness and was diagnosed with a stroke. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided 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 Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dynasys Electro-acupuncture device, implantable neurostimulator, pulse generator, any type (L8679) percutaneous implantation of neurostimulator electrode array (64555).

You asked the Plan to pre-approve Dynasys Electro-acupuncture device. You say that it was determined by the provider that the enrollee would be an excellent candidate for the PENS (percutaneous electrical nerve stimulation) unit to help with chronic pain and reduce the use of controlled substances The Plan denied your request. The Plan says this device is non-covered by Medicare when used for acupuncture (stimulation of auricular acupuncture points) for any indication.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Dynasys Electro-acupuncture device have not been met. Therefore, we decided that the Plan does not have to pre-approve Dynasys Electro-acupuncture device, implantable neurostimulator, pulse generator, any type (L8679) percutaneous implantation of neurostimulator electrode array (64555).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 2 Power Wheelchair (K0823) to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve the Group 2 Power Wheelchair. You say that the power wheelchair is medically necessary. The Plan denied your request. The Plan says the enrollee is eligible for the power wheelchair; however the requested provider is out-of-network. There are network providers available.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 at issue in this appeal. We found no exception that would require the Plan to pre-approve these items. Therefore, we decided that the Plan does not have to pre-approve a Group 2 Power Wheelchair (K0823) 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 for the problem focused limited oral evaluation, preventive procedure, and each additional intraoral periapical x-ray provided on November 24, 2020.

You asked the Plan to pay for the problem focused limited oral evaluation, preventive procedure, and each additional intraoral periapical x-ray. You say that you feel that these services should be covered. The Plan denied your request. The Plan says the problem focused limited oral evaluation and preventive procedure are not covered benefits. The Plan also says that your benefits for intraoral periapical x-rays had been satisfied and the frequency limitation had 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, problem focused limited oral evaluation and unspecified preventive procedure are not among those covered under this benefit. The contract clearly states that intraoral x-rays are limited to one procedure per calendar year. The record shows that you received a first intraoral periapical x-ray on November 24, 2020, and your intraoral x-rays benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation, preventive procedure, and each additional intraoral periapical x-ray provided on November 24, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says there is no clinical advantage of the LTACH over the acute hospital.

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. Our physician reviewer found there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 

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 admission to a long term acute care hospital (LTACH) for the enrollee.
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. 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 B. Colon Gonzalez, 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.