Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CPAP device (E0601).
You asked the Plan to pre-approve a CPAP. You say that you have been using this machine for sleep for 15 years and have never had a problem with previous insurance. The Plan denied your request. The Plan says rules for a CPAP have not been met.
The Plan must follow Medicare rules. Medicare rules say that coverage for a CPAP requires objective evidence of adherence to use of the PAP device. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a CPAP have not been met. Specifically, the case record does not contain objective documentation of your compliance with CPAP treatment. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pre-approve a CPAP device (E0601).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve alveoloplasty (D7310) for all four quadrants, placements of intra-socket biological dressings (D7922) and bone replacement grafts (D7953).
You asked the Plan to pre-approve the dental services. You say that these services are necessary for you to have the teeth extracted and get dentures. The Plan denied your request. The Plan says these services are not covered by Medicare or by the Plan's supplemental dental benefit.
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 alveoloplasty (D7310) for all four quadrants, placements of intra-socket biological dressings (D7922) and bone replacement grafts (D7953).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation system (E2300).
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your request. The Plan says this is not primarily medical in nature.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system (E2300).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services described by current procedural terminology (CPT) code 99358 provided on November 10, 2020 and November 11, 2020.

You asked the Plan to pay for CPT code 99358. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as 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. 

In this case, the CPT Code Manual definition of code 99358 is Prolonged evaluation and management service before and/or after direct patient care; first hour. 

We find that CPT code 99358 is not supported in the medical record. Specifically, CPT code 99358 is used when a prolonged service is provided that is neither face-to face time in the office or outpatient setting, nor additional unit/floor time in the hospital or nursing facility setting during the same session of evaluation and management and is beyond the usual physician or other qualified health care professional service time. This code may be reported on a different date than the primary service to which it is related. The provider's documentation in the medical record indicates that the time was spent coordinating care with other providers after face to face time with the patient. Based on this information, we decided that Medicare rules for coverage of CPT code 99358 have not been met. Therefore, we decided that the Plan does not have to pay for the physician services described by current procedural terminology (CPT) code 99358 provided on November 10, 2020 and November 11, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Positron Emission Tomography (PET) scan (78815).

You asked the Plan to pre-approve the PET scan. You say that the PET scan is medically necessary. The Plan denied your request. The Plan says coverage rules are not met.

The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically necessary. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the PET scan. Our reviewer says that the PET scan is not medically necessary. Our physician reviewer found the enrollee underwent treatment in 2014. There has been no recent change in the patient's condition. This PET scan is surveillance in nature and is not indicated. 

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 PET scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a Positron Emission Tomography (PET) scan (78815).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot inserts.
You asked the Plan to pre-approve the inserts. You say that this is medically necessary. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot inserts.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an injection to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve an injection. You say that you need this injection to walk. The Plan denied your request. The Plan says there are in-network providers available to provide these services.
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 an injection 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 pre-approve a standing frame.
You asked the Plan to pre-approve the frame. You say that this is medically necessary. The Plan denied your request. The Plan says this is not covered for use inside the home.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a standing frame.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.
You asked the Plan to pre-approve incontinence supplies. You say that you would like to be reimbursed. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chiropractic manipulative treatments to be provided by an out-of-network provider.
You asked the Plan to pre-approve chiropractic manipulative treatments. You say that you are temporarily in Texas due to the pandemic. You say that if you cannot receive these treatments you won't be able to get back to California for your necessary surgeries. The Plan denied your request. The Plan says in-network providers are available.
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 pre-approve chiropractic manipulative treatments. Our reviewer says that there is no indication that you require emergency or urgently needed services. Our physician reviewer found that there is no evidence of significant or unusual x-ray, MRI or any evidence of pathological findings, evidence of significant trauma or any other evidence of unusual findings or circumstances requiring this treatment. Our reviewer says that the services do not qualify as emergency or urgently needed services with an out-of-network chiropractor. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of chiropractic manipulative treatments have not been met. Therefore, we decided that the Plan does not have to pre-approve chiropractic manipulative treatments to be provided by an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the infusion services provided on July 28, 2020.
You asked the Plan to waive the coinsurance for the infusion services. You say that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received infusion services on the date of service at issue in this appeal. The Plan says that the correct coinsurance has applied per your contract with the Plan.
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 20% coinsurance for Medicare Part B prescription drugs. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received infusion services on July 28, 2020. You have been asked to pay a 20% coinsurance for the infusion services, totaling $226.84. The infusion services fall within the Medicare Part B prescription drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the infusion services provided on July 28, 2020.
Your complaint about the Plan's explanation for why the claims were processed with the incorrect cost share 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous spacer placement (22869).
You asked the Plan to pre-approve the interspinous spacer placement. You say that the procedure is medically necessary. The Plan denied your request. The Plan says this procedure is investigational and is not covered.
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 interspinous spacer placement. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found Interspinous spacers remain experimental for use in spine surgery. More research is needed to show safety and efficacy. 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 interspinous spacer placement have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous spacer placement (22869).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMEMs device (33289, C2624).
You asked the Plan to pre-approve the CardioMEMs device. You say that the device is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
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 CardioMEMs device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the clinical documentation in the case file does not support that the CardioMEMS implantable device is medically reasonable and necessary for the enrollee in this case. 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 CardioMEMs device have not been met. Therefore, we decided that the Plan does not have to pre-approve a CardioMEMs device (33289, C2624).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a Vertiflex device (22869, 22870).
You asked the Plan to pre-approve the insertion of a Vertiflex device. You say that this is medically necessary.
The Plan denied your request. The Plan says this is experimental.
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 insertion of a Vertiflex device. Our
reviewer says that the requested services are not considered medically reasonable and necessary in this case.
Our physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and
efficacy.
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 insertion of a Vertiflex device have not been met. Therefore, we decided
that the Plan does not have to pre-approve the insertion of a Vertiflex device (22869, 22870).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the insertion of anterior segment aqueous drainage device described by current procedural terminology code 0191T provided on October 19, 2020.

You asked the Plan to pay for CPT code 0191T. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.

The Plan must follow Medicare rules. The rules say that diagnosis codes must be billed with the most precise code that most fully explains the narrative description of the symptom or diagnosis. 

We looked at the file and Medicare rules. In this case, the diagnosis codes billed are not listed as covered codes for CPT code 0191T per Medicare guidelines. Therefore, we decided that the Plan does not have to pay for the insertion of anterior segment aqueous drainage device described by current procedural terminology code 0191T provided on October 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a recliner chair with a massage feature.

You asked the Plan to pre-approve a massaging recliner. You say that the requested item is a necessity for you. The Plan denied your request. The Plan says coverage criteria have not been met.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. 

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a recliner chair with a massage feature.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says experimental and investigational procedures are not covered by Medicare.

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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device is experimental. More research is needed to show safety and efficacy. 

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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
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 services are medically necessary. The Plan denied your request. The Plan says coverage criteria has 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 this patient 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 waive the copayment for a specialist visit provided on October 2, 2020.

You asked the Plan to waive the copayment for a specialist visit. You say that you provider referred you to another provider and feel misled. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 copayment for Tier 2 specialists. 

You have been asked to pay a $50 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a specialist visit provided on October 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says the available medical evidence is conflicting to show if the procedure is safe and helpful.
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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device is experimental. More research is needed to show safety and efficacy. 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the occlusal guard - soft appliance, full arch (D9945) received November 24, 2020.

You asked the Plan to pay for the occlusal guard (D9945). You say that you do not see a list of covered or uncovered services in the plan contract. The Plan denied your request. The Plan says the requested service is not covered under your supplemental benefit.

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 Plan's list of covered services can be found on pages 4-72 through 4-86 of the 2020 Evidence of Coverage. Per page 4-74, any services not listed are not covered. D9945 is not listed among the Plan's covered benefits. Therefore, we decided that the Plan does not have to pay for the occlusal guard - soft appliance, full arch (D9945) received November 24, 2020.