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

We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140)
provided April 7, 2021.
You asked the Plan to pay for the limited oral exam. You say that you would like the service to be covered. The
Plan denied your request. The Plan says this service is 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 pay for the
limited oral evaluation - problem focused (D0140) provided April 7, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for an office visit (99213) provided on February 17, 2021 by an out-ofnetwork
(OON) provider.

You asked the Plan to pay for an office visit. You say that you were told that the enrollee had a PPO plan. The
Plan denied your request. The Plan says that OON services require authorization.

Medicare rules say that plans can require enrollees to get care from network providers. However, the contract
with the Plan says that the Plan will cover services from either in-network or out-of-network providers, as long
as the services are covered benefits and medically necessary. The Plan contract also says that enrollees don't
need to get a referral or prior authorization to get care from out-of-network providers.

The Plan has denied the service at issue on the basis of out-of-network providers requiring authorization.
However, the Plan contract specifically states that authorization is not required for out-of-network services.
Therefore, we decided that the Plan has to pay for an office visit (99213) provided on February 17, 2021 by an
out-of-network (OON) provider.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for polycarbonate lens (V2784) provided on
March 10, 2021.
You asked the Plan to reimburse you for the polycarbonate lens (V2784). The Plan denied your request. The Plan says the bifocal lenses were covered although, the polycarbonate lens was offered to you at a special price of a $35 fee. You are responsible and have already paid for the additional copay for antiglare coating and polycarbonate upgrades or "enhancements."
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine 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. The file shows that the Plan does not offer coverage for enhancements for eyeglasses. Therefore, we decided that the Plan does not have to reimburse you for polycarbonate lens (V2784) provided on March 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the shower chair, for the enrollee.
You asked the Plan to pre-approve a shower chair. You say that the shower chair is necessary. The Plan denied your request. The Plan says this item is not a covered benefit of Medicare.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve the shower chair, for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Transcutaneous Electrical Nerve Stimulator (TENS) unit (E0730).
You asked the Plan to pre-approve the TENS unit. You say that the TENS unit is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that TENS units are covered when 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 TENS unit. Our reviewer says that the TENS unit is not medically necessary. Our physician reviewer found Lumbar radiculopathy is considered a subset of chronic low back pain and the beneficiary is not enrolled in a qualifying clinical study to meet requirements. There is no documentation that the pain has been present more than 3 months or that other appropriate treatment modalities have been tried and failed. 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 TENS unit have not been met. Therefore, we decided that the Plan does not have to pre-approve a Transcutaneous Electrical Nerve Stimulator (TENS) unit (E0730).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tecentriq, Carboplatin, and Etoposide.
You asked the Plan to pre-approve Tecentriq, Carboplatin, and Etoposide. You say that this request is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the clinical value and effectiveness of Tecentriq, Carboplatin, and Etoposide for the enrollee's condition have not been demonstrated in the peer-reviewed literature.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Tecentriq, Carboplatin, and Etoposide. Our reviewer says that this drug regimen is not medically necessary for the enrollee's condition. Our physician reviewer found the enrollee disease is currently progressing on the current drug regiment. The latest scans show worsening liver metastatic disease. Per the Medicare-approved compendia, as there is progression of the disease it is not medically reasonable or necessary to continue the same regimen.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Tecentriq, Carboplatin, and Etoposide have not been met. Therefore, we
decided that the Plan does not have to pre-approve Tecentriq, Carboplatin, and Etoposide.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a vertebral axial decompression service with a chiropractor.
You asked the Plan to pre-approve a vertebral axial decompression (S9090). You say that you are in significant pain and do not want surgery. The Plan denied your request. The Plan says this procedure is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.
The records show that the service at issue is not manual manipulation of the spine. The code is incorrect, and this procedure is not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve a vertebral axial decompression service with a chiropractor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on March 22, 2021.
You asked the Plan to pay for the problem focused limited oral evaluation. You say that this was an emergency visit for a broken tooth, not a routine visit. The Plan denied your request. The Plan says this service exceeds the frequency limitation in your benefit plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, problem focused limited oral evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem focused limited oral evaluation (D0140) on March 4, 2021 and your problem focused limited oral evaluation (D0140) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the problem
focused limited oral evaluation (D0140) provided on March 22, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ondansetron tab.
You asked the Plan to pre-approve Ondansetron tab. You say that this medication will be used at home post chemotherapy. The Plan denied your request. The Plan says the requested drug does not meet the Medicare criteria for coverage under Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested is not covered by Medicare Part B because the record shows this medication is not for use within 2 hours of chemotherapy and not to be used as a full therapeutic replacement for intravenous anti-emetic therapy. Therefore, we decided that the Plan does not have to pre-approve Ondansetron tab.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from February 3, 2021 to February 24, 2021.
You asked the Plan to pay for home health services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this claim has not been billed with the required through date or revenue code.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the submitted claim was not billed with an appropriate revenue code the indicate the non-routine supplies.. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from February 3, 2021 to February 24, 2021.
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 IRF care is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for IRF care have not 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 the patient was admitted for urinary tract infection, pneumonia and a diabetic foot ulcer. Medical conditions are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The patient 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. In conclusion, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the endodontic therapy (D3330) and preventive procedure (D1999) provided on November 9, 2020.
You asked the Plan to pay for the endodontic therapy and preventive procedure. You say that you were advised that this service would be covered. The Plan denied your request. The Plan says you have exceeded your benefit period program maximum.
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 Plan offers a Calendar Year Maximum of up to $1,000. The contract also says that you must pay a 50% coinsurance for a root canal
treatment. The record shows that your calendar year maximum benefit had been exhausted while processing this claim for the November 9, 2020. This leaves you responsible for a total of $501.20, which is the difference between the amount the Plan paid ($408.80) and the allowed amount ($910.00), because you exceeded your calendar year maximum. Therefore, we decided that the Plan does not have to pay for the endodontic therapy (D3330) and preventive procedure (D1999) provided on November 9, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the imaging services rendered on December 15, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 75625 is not supported.
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 75625 is aortography, abdominal, by serialography, radiological supervision and interpretation. We find that CPT code 75625 is not supported in the medical record. Specifically, there is no documentation of
radiological supervision and interpretation of abdominal aortography by serialography. 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 for the imaging services rendered on December 15, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on February 25, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal, prostate predictive screening, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on February 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the right shoulder elbow wrist hand orthosis provided on
September 14, 2020.

You asked the Plan to pay for the right shoulder elbow wrist hand orthosis. You say that you would like the
plan to reconsider their denial. The Plan denied your request. The Plan says the item is not payable as billed.

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 right shoulder
elbow wrist hand orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the
right shoulder elbow wrist hand orthosis provided on September 14, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the COVID-19 vaccine received on February 5, 2021.
You asked the Plan to pay for the COVID-19 vaccine. You say that you feel this claim should be paid. The Plan denied your request. The Plan says these services should be submitted to Original Medicare.
Medicare rules say that Original Medicare, not the Plan, is responsible for all COVID-19 vaccines. The rules say that the Plan may direct the provider to bill Medicare directly for these services. Review of the file shows that the services at issue in this appeal is the COVID-19 vaccine received. Per Medicare rules, these services should be submitted to Original Medicare for payment. This means that the Plan is not responsible for payment of the COVID-19 vaccine. Therefore, we decided that the Plan does not have to pay for the COVID-19 vaccine received on February 5, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the uvulectomy (CPT code 42140), for the enrollee.
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your
request. The Plan says the clinical value and effectiveness of a uvulectomy in the absence of an enlarged uvula
have not been demonstrated in the peer-reviewed literature.
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 service. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found a UPPP includes removing a portion of the uvula through a wedge excision. Therefore, a
uvulectomy should not be separately billed from the UPPP.
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 service have not been met. Therefore, we decided that the Plan does not
have to pre-approve the uvulectomy (CPT code 42140), for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level (CPT code 64493), for the enrollee.
You asked the Plan to pre-approve the injection. You say that the enrollee has 80% reduction for short period of time and the enrollee is candidate for radiofrequency ablation. The Plan denied your request. The Plan says that the Medicare rules have not been met.
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 injection. Our physician reviewer found the request for a second set of diagnostic medial branch nerve block (MBBs) is required by the LCD prior to radiofrequency ablation (RFA). The request is medically reasonable and 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 injection have been met. Therefore, we decided that the Plan has to pre-approve injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level (CPT code 64493), for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of SNF care from July 15, 2021, forward.

You asked the Plan to pre-approve SNF care. You say that you need additional care because your conditions are improving after the massive stroke. The Plan denied your request. The Plan says the stay is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there is no documentation that you require skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse are not required to safely and effectively provide medically necessary and reasonable treatment. You do require skilled therapy services, i.e., the specialized skill, knowledge and judgment of a qualified therapist are required to safely and effectively provide medically necessary and reasonable treatment. Daily skilled services are not required. You do not require the services on an inpatient basis, only in a SNF setting. Services in a long-term care facility on a part time basis appear appropriate 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of SNF care from July 15, 2021, forward.