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

We decided that the Plan does not have to pay more for the comprehensive oral evaluation, prophylaxis and intraoral x-ray provided on December 23, 2020.
You asked the Plan to pay more for the comprehensive oral evaluation, prophylaxis and intraoral x-ray. The Plan denied your request. The Plan says the claim reprocessed to apply 50% coinsurance for the comprehensive oral evaluation and prophylaxis.
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 also pay 50% coinsurance for a comprehensive oral evaluation and prophylaxis from an out-of-network provider. The intraoral x-ray is not a covered benefit. You are also responsible for any amount greater than the payment made by the Plan to the provider. Therefore, we decided that the Plan does not have to pay more for the comprehensive oral evaluation, prophylaxis and intraoral x-ray provided on December 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve removal of impacted tooth (D7230 x4), and anesthesia for intraoral procedures (00170).
You asked the Plan to pre-approve removal of impacted tooth, and anesthesia for intraoral procedures. You say that the services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are not covered benefits.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve removal of impacted tooth (D7230 x4), and anesthesia for intraoral procedures (00170).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a therapeutic continuous glucose monitor and supplies.

You asked the Plan to provide a therapeutic continuous glucose monitor and supplies. You say that the enrollee
has been using a CGM. The Plan denied your request. The Plan says criteria is not met for a CGM.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based
on the blood glucose testing results and have had an in-person visit with their treating physician to assesses
adherence to their CGM regimen and diabetes treatment plan.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood
glucose testing at least four times per day or requires frequent self- adjustment of insulin dosage based on the
testing results. Based on this information, we decided that Medicare rules for coverage of a therapeutic
continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to provide a
therapeutic continuous glucose monitor and supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a heavy-duty manual wheelchair (K0006) and accessories (K0052, E0705).

You asked the Plan to pre-approve a heavy-duty manual wheelchair and accessories. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says you do not meet Medicare criteria.

The Plan must follow Medicare rules. Medicare rules say that a manual wheelchair may be considered medically necessary when all of the above criteria are met. 

We looked at the file and Medicare rules. The file does not show that you have a mobility limitation that significantly impairs your ability to participate in one or more mobility-related activities of daily living. The file does not show that your mobility limitations cannot be sufficiently resolved by the use of an appropriately fitted cane or walker. Therefore, we decided that the Plan does not have to pre-approve a heavy-duty manual wheelchair (K0006) and accessories (K0052, E0705).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an implant supported porcelain/ceramic crown (D6065), custom fabricated abutment - includes placement (D6057), and surgical placement of implant body: endosteal implant (D6010).

You asked the Plan to pre-approve an implant supported crown, custom fabricated abutment and endosteal implant. You say that you cannot afford the cost of the services on your own. The Plan denied your request. The Plan says these services are 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 pre-approve an implant supported porcelain/ceramic crown (D6065), custom fabricated abutment - includes placement (D6057), and surgical placement of implant body: endosteal implant (D6010).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for sedation services (99152) provided June 12, 2020.
You asked the Plan to pay for the sedation services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services billed.
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 CPT code 99152 is not supported in the medical record. Specifically, there was no documentation of anxiety or psychiatric disorders, or cognitive impairments that would support this service. The plan requested additional records and supporting documentation was not provided. Based on this information, we decided that Medicare rules for coverage of the sedation services have not been met. Therefore, we decided that the Plan does not have to pay for sedation services (99152) provided June 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental
pneumatic appliance (E0667).

You asked the Plan to pre-approve a pneumatic compression device and appliance. You say that if she can use
this device as part of her plan of care, she will not have to go to therapy and will be able to manage her
lymphedema. The use of the E0651 causes her too much pain. The Plan denied your request. The Plan says the
enrollee does not meet the LCD criteria for an advanced lymphedema pump as there is no failed four-week trial
of a basic pneumatic compression device of either E0650 or E0651.

The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily,
multiple-hour home usage of the E0650 or E0651 is required.

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting,
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device
(E0652) and segmental pneumatic appliance (E0667).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider.
You asked the Plan to pre-approve these services. You say that the enrollee has a complex surgical history. The Plan denied your request. The Plan says the services are available from 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-approve a referral to an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the consultation and extraction to be provided by an oral surgeon.

You asked the Plan to pre-approve the consultation and extraction. You say that you were referred to an oral surgeon for an extraction. The Plan denied your request. The Plan says your contract only provides coverage for dental services performed by a participating general dentist. 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, dental services provided by an oral surgeon are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the consultation and extraction to be provided by an oral surgeon.
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 the doctor does not recommend you go home. You say that IRF care is needed for strengthening. You say that you have limited ability with the right side of your body. You say that you were not able to walk on your own, use your right hand, or speak correctly. The Plan denied your request. The Plan says the notes received do not show that the enrollee has a medical need for IRF care.

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 the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for a stroke. The enrollee's medical conditions are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this enrollee 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on December 29, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the office visit. You say that this visit does not need authorization and the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
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 office visit provided on December 29, 2020 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (81479) provided December 15, 2020.
You asked the Plan to pay for the genetic testing. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services billed.
The Plan must follow Medicare rules. Medicare rules say that Next Generation Sequencing (NGS) as a diagnostic laboratory test is reasonable and necessary and covered nationally, when performed in a Clinical Laboratory Improvement Amendments (CLIA)-certified laboratory, when ordered by a treating physician. We looked at the file and Medicare rules. A valid physician order was not included in the records. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (81479) provided December 15,
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an extremity brace (L0650) provided October 31, 2020.
You asked the Plan to pay for the extremity brace. You say that the items were medically necessary. The Plan denied your request. The Plan says the documentation does not support that the brace was medically necessary. The brace was provided as a result of an unsolicited telehealth consult.
The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone regarding the furnishing of a covered item except under specific circumstances. We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an
unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the enrollee's treating physician. The record does not show that written permission was obtained to make contact by telephone regarding the furnishing of this item. The record does not show that contact was initiated regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the past 15 months. Based on this information, we decided that Medicare rules for coverage of the extremity brace have not been met. Therefore, we decided that the Plan does not have to pay for an extremity brace (L0650) provided October 31, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the red egg switch, controller Q-logic joystick, sip and puff, and seat cushion cover requested for a power wheelchair.
You asked the Plan to pre-approve the switches, controller terminals, and seat cushion cover. You say that all requested items should be approved. The Plan denied your request. The Plan says the wheelchair and necessary components were approved for coverage. The denied components are included in the approved services and cannot be separately approved.
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 switches, controller terminals, and seat cushion cover. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found review of the records shows that the separately requested controller and switch components serve the same purpose as the other equipment already approved for the enrollee. The switches, joystick and sip and puff interface are already included with the approved equipment. The code requested for the cushion cover is also only allowed for replacement and is not payable at initial issue. 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 switches, controller terminals, and seat cushion cover have not been met. Therefore, we decided that the Plan does not have to pre-approve the red egg switch, controller Q-logic joystick, sip and puff, and seat cushion cover requested for a power wheelchair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient services provided from December 7, 2020, through December 10, 2020 with the reported principal diagnosis J18.9, pneumonia.
You asked the Plan to pay for inpatient services provided from December 7, 2020, through December 10, 2020 with the reported principal diagnosis J18.9, pneumonia. The Plan denied your request. The Plan says the medical records do not support the DRG billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services provided with principal diagnosis of pneumonia, J18.9. 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 inpatient services provided from December 7, 2020, through December 10, 2020 with the reported principal diagnosis J18.9, pneumonia. Our reviewer says that the documentation does not support that the inpatient care is payable as billed. Our physician reviewer found that the enrollee was a then, 66-year-old male who was admitted from home on December 7, 2020 with shortness of breath for three weeks above his baseline with a need for oxygen (O2) at home. Home O2 was not helping. The enrollee had COVID-19 in April 2020 and has had an O2 requirement since that time. Two notes of respiratory failure in the documents, state for chronic, not acute respiratory failure. The sepsis diagnosis criteria were not met according to the review. DRG 194 was paid and is upheld. The review has determined that the principal diagnosis of hospital acquired pneumonia, J18.9 is not supported by the medical records. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient services provided from December 7, 2020 to December 10, 2020 with the reported principal diagnosis J18.9, pneumonia.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair expandable controller represented by code E2377, a power wheelchair access harness upgrade represented by code E2313 and an electronic connection between a wheelchair controller and two or more power seating system motors, represented by code E2311.

You asked the Plan to pre-approve codes E2377, E2313, and E2311. You say that the enrollee is confined to a wheelchair for all of her activities of daily living. You say that all of the requested items are medically necessary for the enrollee so that she can move around her home safely. The Plan denied your request. The Plan says the enrollee's upper limb strength and function are adequate for the enrollee to be able to control the power options using their own switches, which are included in the allowance of these power options.

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 codes E2377, E2313, and E2311. Our reviewer says that the items represented by codes E2377, E2313, and E2311 are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested accessories which remain in dispute are not medically necessary as the enrollee does have use of her hands and can operate and control the power options using the switches that are included in the approved wheelchair.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of codes E2377, E2313, and E2311 have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair expandable controller represented by code E2377, a power wheelchair access harness upgrade represented by code E2313 and an electronic connection between a wheelchair controller and two or more power seating system motors, represented by code E2311.