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

We decided that the Plan does not have to pre-approve porcelain or ceramic crowns for tooth #'s 6 and 7.
You asked the Plan to pre-approve the crowns. You say that the enrollee's crowns came off of tooth #'s 6 and 7. The Plan denied your request. The Plan says these services exceed the maximum count allowed per period.
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, crown - porcelain/ceramic is limited to one procedure every five years. The record shows that you received a porcelain or ceramic crown on tooth #6 on January 16, 2018 and a porcelain or ceramic crown on tooth #7 on November 1, 2017 and your porcelain/ceramic crown benefit for tooth #'s 6 and 7 is now exhausted. Therefore, we decided that the Plan does not have to pre-approve porcelain or ceramic crowns for tooth #'s 6 and 7.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea commode chair (E0165), standard wheelchair (K0001), and a walker (E0143).You asked the Plan to pre-approvethe services. You say that this is medically necessary.The Plan denied your request. The Plan says the records do not show an examination by the primary doctor in order for the decision to be made for these items.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 items/services are not considered medically reasonable and necessary in this case. Our physicianreviewer found in terms of the commode, the documentation does not support that you are confined to a single room, or confined to one level of the home environment and there is no toilet on that level, or confined to the home and there are no toilet facilities in the home. In terms of the walker, the documentation does not reveal evidence that you have a mobility limitation that significantly impairs her ability to participate in one or more mobility-related activities of daily living (MRADLs) in the home.In terms of the wheelchair, the documentation does not reveal that you have a mobility limitation that impairs ability to perform MRADLs in the home. There is no detailed upper and lower extremity neuromuscular exam that reveals whether your mobility limitation can be sufficiently resolved by the use of an appropriately fitted cane or walker. There is no home evaluation revealing whether the home has adequate access between rooms, maneuvering space, and surfaces for use of the manual wheelchair that is provided. The documentation does not reveal whether you can safely use this wheelchair or have a caregiver that is willing to push the wheelchairWe 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-approvea commode chair (E0165), standard wheelchair (K0001), and a walker (E0143)
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for (CPT Code A6441), CPT Code A6445), (CPT Code A6448), (CPT Code A6449) and (CPT Code A6450) provided to the enrollee on June 6, 2019.

You asked the Plan to pay for the DME. You say that the claim should be paid. The Plan denied your request. The Plan says the records do not support the services.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met.

Healthcare Common Procedure Coding System (HCPCS) code A6445-KX (73 Units) remains not supported.  The documentation submitted did not include a valid physician order; therefore, the billed service cannot be verified. In addition, the documentation submitted did not include an itemized shipping/billing invoice to indicate the specific supplies, or proof of delivery. It is noted that multiple attempts were made to contact the provider for additional information. 

Healthcare Common Procedure Coding System (HCPCS) code A6441-KX (248 Units) remains not supported.  The documentation submitted did not include a valid physician order; therefore, the billed service cannot be verified. In addition, the documentation submitted did not include an itemized shipping/billing invoice to indicate the specific supplies, or proof of delivery. It is noted that multiple attempts were made to contact the provider for additional information.

Healthcare Common Procedure Coding System (HCPCS) code A6450-KX (708 Units) remains not supported.  The documentation submitted did not include a valid physician order; therefore, the billed service cannot be verified. In addition, the documentation submitted did not include an itemized shipping/billing invoice to indicate the specific supplies, or proof of delivery. It is noted that multiple attempts were made to contact the provider for additional information. 


Healthcare Common Procedure Coding System (HCPCS) code A6449-KX (118 Units) remains not supported.  The documentation submitted did not include a valid physician order; therefore, the billed service cannot be verified. In addition, the documentation submitted did not include an itemized shipping/billing invoice to indicate the specific supplies, or proof of delivery. It is noted that multiple attempts were made to contact the provider for additional information.

Healthcare Common Procedure Coding System (HCPCS) code A6448-KX (118 Units) remains not supported.  The documentation submitted did not include a valid physician order; therefore, the billed service cannot be verified. In addition, the documentation submitted did not include an itemized shipping/billing invoice to indicate the specific supplies, or proof of delivery. It is noted that multiple attempts were made to contact the provider for additional information. Therefore, we decided that the Plan does not have to pay for (CPT Code A6441), CPT Code A6445), (CPT Code A6448), (CPT Code A6449) and (CPT Code A6450) provided to the enrollee on June 6, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay foran additional eye exam performed on July 29, 2019.You asked the Plan to pay foran additional eye exam. You say that the services are medically necessary. You state that you are asking the Plan to provide you with an additional routine eye exam at no charge for 2019.The Plandenied your request. The Plan says this is not approved for coverageMedicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of an additional eye exam have not been met. Your EOC clearly states, a Routine Eye Exam (1 per calendar year).Therefore, we decided that the Plan does not have to pay foran additional eye exam performed on July 29, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more forthe two amalgams and two resin-based composites provided on August 6, 2019 and August 14, 2019.You asked the Plan to pay more forthe amalgams and resin-based composites. You say that after your dental visit on August 6, 2019, you were assured that you owed nothing and therefore, assumed that the Plan was paying for the services rendered. You also say that you concludedthat the Plan would pay all of or part of the bill.The Plan denied your request. The Plan says that theservices in dispute were performed by a non-participatingprovider. The Plan says that the cost sharing amount applied to the covered services was appropriate. The Plan also says that the services in dispute which were denied exceeded thefrequency limitations for restoration services.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 contract clearly states that enrollees are responsible for the difference between the INFS and the dentists' charged fees when visiting an out-of-network provider.The contract also says that restorations are limited to two procedures per calendar year. The record shows that you received one amalgam and one resin-based composite on August 6, 2019 and your restorations benefit was then exhausted. Therefore, we decided that the Plan does not have to adjust the cost-sharing amount applied tothe amalgam and theresin-based composite provided on August 6, 2019 or for the second amalgam provided on August 14, 2019.Your complaint about being wronged by the Planis 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for diabetic foot orthotics provided to the enrollee on January 29, 2019, by an out-of-network provider.
You asked the Plan to pay for the diabetic foot orthotics. You say that the claim should be paid. The Plan denied your request. The Plan says the provider is a non-network provider who does not work with the member's plan, and the member self-directed for care. The Plan states the member's primary care provider did not refer for services and the plan requires utilization of network providers when possible and available, and requires authorization for certain 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 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 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 diabetic foot orthotics provided to the enrollee on January 29, 2019, by an out-of-network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
The enrollee asked the Plan to pay for the ambulance services. The enrollee said that an ambulance was called because the enrollee was having difficulty breathing, weakness and dizziness. Paramedics arrived and began evaluating and checking the enrollee's vitals. The enrollee stated that they began to improve and since they were beginning to feel better they declined transportation to the hospital. The Plan denied the enrollee's request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on August 17, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forblood glucose monitor with integrated voice synthesizer (CPT Code E2100), blood glucose test or reagent strips for home blood glucose monitor, per 50 strips (CPT Code A4253), lancets, per box of 100 (CPT Code A4259), normal, low and high calibrator solution / chips (CPT Code A4256) and spring-powered device for lancet, each (CPT Code A4258) provided to the enrollee from July 29, 2019 through October 17, 2019.You asked the Plan to pay forthe DME. You say that the claim should be paid.The Plan denied your request. The Plan says the records do not support the services.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. The Delivery Ticket submitted did not include the carrier's tracking number, nor did the Proof ofDelivery include an order number or details to corroborate the Delivery Ticket submitted. Of note, the Proof of Delivery is not itemized to indicate the specific supplies; therefore, the billed supply code cannot be verified.Therefore, we decided that the Plan does not have to pay forblood glucose monitor with integrated voice synthesizer (CPT Code E2100), blood glucose test or reagent strips for home blood glucose monitor, per 50 strips (CPT Code A4253), lancets, per box of 100 (CPT Code A4259), normal, low and high calibrator solution / chips (CPT Code A4256) and spring-powered device for lancet, each (CPT Code A4258) provided to the enrollee from July 29, 2019 through October 17, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a multi-level lumbar fusion (22614). You asked the Planto pre-approvea multi-level lumbar fusion. You say that the services are medically necessary.The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 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 a multi-level lumbar fusion. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the medical records show thatonly the L4-5 level has spondylolisthesis and slippage. There is no instability at any other level. Fusion is only needed at L4-5.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a multi-level lumbar fusion have not been met.Therefore, we decided that the Plan does not have to pre-approvea multi-level lumbar fusion (22614).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approveimplantation of a cranial (hypoglossal) nerve neurostimulator (0466T, 64568) for obstructive sleep apnea (OSA).You asked the Plan to pre-approvea hypoglossal nerve neurostimulator. You say that the Plan's denial does not conform to Medicare requirements.The Plan denied your request. The Plan says this is not a covered item under Medicare.The Plan must follow Medicare rules. The rules say that it is clear that additionalpublished literature is needed and that prospective comparative blinded and randomized trials with clinically meaningful outcome measures are required to fully evaluate whether this device meets Medicare coverage requirements. The rules also say that CPT code 0466T will be denied as not reasonable and necessary.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a hypoglossal nerve neurostimulator have not been met.Specifically, this service is not a covered benefit for the jurisdiction (Wisconsin) in this case. In addition, the requested code (0466T) is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pre-approveimplantation of a cranial (hypoglossal)nerve neurostimulator (0466T, 64568) for obstructive sleep apnea (OSA)
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadditional personal attendant services hours.You asked the Planto pre-approvethe additional hours. You say that the hours should not have been reduced.The Plandenied your request. The Plansaysit is medically reasonable to reduce the hours from 28 hours/7 days a week to 17 hours/6 days a week.The Plan must follow Medicare rules. Medicare rulessay 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 additional hours. Our reviewer says that the requested additional hours are not considered medically reasonable and necessary in this case. reduction of Personal Attendant Services from 28 hours per 7 days a week to 17 hours per 6 days a week. You hada recent assessment on 11-21-19which indicated per the AGP PAS Tool he/she qualified for 17 hours per week. The functional assessment indicated you are standby assist with bathing and dressing, no impairments with feeding or grooming, no impairments withtoileting, and transfers and mobility with standby assist. The most recent evaluation indicates 17 hours per week are medically necessary. The remaining requested hours are not medically necessary and not supported by the clinical documentation. Our physician reviewer found the appeal concerns theWe looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the additional hours have not been met.Therefore, we decided that the Plandoes not haveto pre-approveadditional personal attendant services hours.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe panoramic x-rays (D0330) provided on October 7, 2019.You asked the Plan to pay forthe panoramic x-rays (D0330). You say that you needed the panoramic film to see what further work needed to be done. The Plan denied your request. The Plan says this service is not a covered 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 panoramic x-rays (D0330) are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay forthe panoramic x-rays (D0330) provided on October 7, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the Cervical Spine (72141).You asked the Plan to pre-approve the MRI. You say that the MRI is medically necessary.The Plan denied your request. The Plan says the MRI is not indicated at this time.The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that coverage criteria has not been met. Our physician reviewer found there are no documented symptoms referable to the cervical spine. MRI of the cervical spine is not medically 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 MRI have not been met.Therefore, we decided that the Plan does not have to pre-approveMagnetic Resonance Imaging (MRI) of the Cervical Spine (72141).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power wheelchair, group 2 standard, captains chair, patient weight capacity up to and including 300 pounds (CPT Code K0823).You asked the Plan to pre-approvethe power wheelchair. You say that the durable medical equipment is medically necessary.The Plan denied your request. The Plan says the Medicare rules have not been met.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the power wheelchair have not been met. There is no home assessment. No physician written order to include the 7 element order. No additional clinical information submitted. No detail order submitted.Therefore, we decided that the Plan does not have to pre-approvepower wheelchair, group 2 standard, captainschair, patient weight capacity up to and including 300 pounds (CPT Code K0823)
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forhome blood glucose monitor (CPT Code E0607), blood glucose test or reagent strips for home blood glucose monitor, per 50 strips (CPT Code A4253), lancets, per box of 100 (CPT Code A4259), spring-powered device for lancet, each (CPT Code A4258) and normal, low and high calibrator solution / chips (CPT Code A4256) provided to the enrollee on June 25, 2019.
You asked the Plan to pay forthe DME. You say that the claim should be paid.The Plan denied your request. The Plan says the records do not support the services.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. The Delivery Ticket submitted did not include the carrier's tracking number, nor did the Proof of Delivery include an order number or details to corroborate the Delivery Ticket submitted. Of note, the Proof of Delivery is not itemized to indicate the specific supplies; therefore, the billed supply code cannot be verified.Therefore, wedecided that the Plan does not have to pay forhome blood glucose monitor (CPT Code E0607), blood glucose test or reagent strips for home blood glucose monitor, per 50 strips (CPT Code A4253), lancets, per box of 100 (CPT Code A4259), spring-powered device for lancet, each (CPT Code A4258) and normal, low and high calibrator solution / chips (CPT Code A4256) provided to the enrollee on June 25, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care rendered from June 4, 2019 to June 5, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services were not medically necessary.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We looked at the file and Medicare rules. The file does not contain any documentation to support a reasonable expectation that the enrollee would require at least two midnights of inpatient hospital care for the dates of service at issue. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay forthe acute inpatient hospital care rendered from June 4, 2019 to June 5, 2019.