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

We decided that the Plan does not have to pay for incontinence supplies provided by the Pharmacy
on August 22, 2019.
You asked the Plan to pay for incontinence supplies. You say that your physician requested the supplies. The
Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that 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 pay for incontinence supplies provided by the Pharmacy on August 22, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approveponticsfor teeth 23, 24, 29 (D6242 ) and retainer crown for teeth 25, 26, 27, 28 (D6752).You asked the Plan to pre-approvethe dental services. You say that you sincerely ask approval of the request for dentures on your lower jaw due to your situation so you can have teeth and will be able to eat.The Plan denied your request. The Plan says the requested treatment is not clinically appropriate.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the dental services when the services are medically necessary and reasonable. 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 dental services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case there is notable bone loss with rather short roots remaining, and clearly insufficient strength remaining to support the requested appliance. Given the status of the remaining teeth, the short roots, periodontal disease and endodontic treatment that will be rendered to abutment teeth, there is no medical necessity for the bridge as it does not follow sound bio-mechanical principles.We looked at this physician's review, the file, and Medicare rules. Based on this information, wedecided that the Plan's rules for coverage of the dental services have not been met.Therefore, we decided that the Plan does not have to pre-approvepontics  for teeth 23, 24, 29 (D6242 ) and retainer crown for teeth 25, 26, 27, 28 (D6752).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plandoes not haveto pay forassistant surgeon services provided to the enrollee on August 26, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysgiven that a provider is a physician assistant, he needed to add modifier -80, -81, or -82 to all the surgical codes, along with modifier -AS, to clearly distinguish that he was a non-physician assisting in the surgical services performed.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 the denied codes is:CPT 22633:Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace and segment; lumbarCPT 22842:Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires) CPT 22634: Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace and segment; lumbarCPT 20936:Autograft for spine surgery only (includes harvesting the graft) 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 the services. Our reviewer says that the services at issue in this case were not coded correctly. Our physician reviewer found the billed services were provided by a physician assistant (PA), who acted as an assistant surgeon during an operation performed on 8/26/2019. When billing for surgical assistant services, modifier 80, 81 or 82 must be attached. Thereafter, if the assistant is not a physician, modifierAS must be attached. The provider/PA has attached modifier AS, but not modifier 80, 81 or 82. Therefore, the services have not been billed correctly.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 services have not been met.Therefore, we decided that the Plandoes not haveto pay forassistant surgeon services provided to the enrollee on August 26, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea dental consultation to be provided by out an of network provider.You asked the Planto pre-approvethe dental service. You say that you need a dental prosthesis as soon as possible. You say that the dental prosthesis that you received from your medical center are too small and you cannot use them. You also say that you do not wish toreceive services from the medical center dentist again.The Plan denied your request. The Plan says the requested provider in this case is not a network provider. The Plan says that dental services must be obtained by your primary care office in order to be covered.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 must be obtained by your primary care office in order to be covered.Therefore, we decided that the Plan does not have to pre-approvea dental consultation to be provided by out an of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea portable oxygen concentrator.You asked the Plan to pre-approvethe requested item. You say that you want to go shopping, and do a lot more on your own.The Plandenied your request. The Plan says the current oxygen equipment is less than five years old.The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary.The file shows that you have an oxygen concentrator. Your current concentrator serves the same purpose as the requested item. Therefore, we decided that the Plan does not have to pre-approvea portable oxygen concentrator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea three wheeled walker.You asked the Plan to pre-approvea three wheeled walker. You say that you need this because a three wheeled walker is not medically necessary because you are able to use a standard four wheeled walker.The Plan denied your request. The Plan says that because it is lighter and it is so much easier to take in and out of the car.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 three wheeled walker. Our reviewer says that a three wheeled walker is not medically reasonable and necessary in this case. Our physician reviewer found that your condition does not meet Medicare criteria for a three wheeled walker. It is not clear that you could not safely and adequately use a lesser device, such as a two wheeled walker or cane.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 three wheeled walker have not been met.Therefore, we decided that the Plan does not have to pre-approvea three wheeled walker.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea neuropathy treatment program for the enrollee.You asked the Planto pre-approvethe program. You say that this is medically necessary.The Plandenied your request. The Plansaysthe best evidence does not indicate the effectiveness of the proposed treatment.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 topre-approve the program. Our reviewer says that the requested program is not considered medically reasonable and necessary in this case. Our physician reviewer found the requested technology has not readily been validated in well designed clinical studiesfor use in patients with neuropathy. The use of this technology is otherwise not within the "accepted standards of medical practice for the diagnosis or treatment of the patient's condition ". Rather there remains a need for further studies of this specific technology to determine its overall efficacy and utility in the management of various forms of neuropathy. Given the need for further study this technology would be investigational and thus would not meet the Medicare definition of medical necessity.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 program have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea neuropathy treatment program for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have topay foremergency room services provided to the enrollee on July 27, 2019.You asked the Plan to pay forthe services. You say that this should be paid for.The Plan denied your request. The Plan says this service is not allowed because the same/similar service has been billed by the same specialty.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 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 the services. Our reviewer says that the services at issue in this case were not supported by the medical records submitted. Our physician reviewer found no provider records for the date of service in question have been submitted. Therefore, there is no evidence that separate and distinct service were provided on the date of service in question. As such, thebilling of what appears to be duplicate services is not supported.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 services have not been met.Therefore, we decided that the Plan does not have to pay foremergency room services provided to the enrollee on July 27, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to adjust the copaymentfor the inpatient skilled nursing facility care provided from May 1, 2019 to May 19, 2019.You asked the Plan to adjust the copayment. You say that you are requesting a reconsideration of the Plan's denial.The Plan denied your request. The Plan says the cost sharing has been applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information(such as copayments, deductibles and coinsurance). Yourcontract with the Plan clearly says that you must pay a $172 copayment per day, for days 21-100 in a skilled nursing facility. You havebeen asked to pay a $3,096 copayment (18days x $172) for inpatient skilled nursing facility services provided, which does not include the day of discharge. This means that you havebeen asked to pay the correct amount based on yourcontract with the Plan. This cost sharing is a contractual obligation youagreed to pay when youenrolled in the Plan.Therefore, we decided that the Plan does not have to adjustthe copaymentfor the inpatient skilled nursing facility care provided May 1, 2019 to May 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe therapy services (97110) provided on August 2, 2019.You asked the Plan to pay forthe therapy services. 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.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.Therefore, we decided that the Plan does not have to pay forthe therapy services (97110) provided on August 2, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to hold you harmless for the manual manipulative treatment (98941), the extra-spinal manipulative treatment (98943), and the electrical stimulation therapy (97032) provided on September 13, 2019.
You asked the Plan to hold you harmless for these services. You say that you do not agree with the denial issued or the claim submitted as you did not receive any services on September 13, 2019 and have not received a diagnosis of Sciatica. The Plan denied your request. The Plan says that the diagnosis code billed is not one that Medicare covers; therefore, the services are not covered by the Plan.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Health plan follows these rules. The rules also say that Medicare plans must make reasonable and diligent efforts to gather and forward information to the Independent Review Entity (IRE). The services at issue were provided by the Health plan, a plan contracted provider. The file does not show that the Health plan provided notice that manual manipulative treatment (98941) would not be covered. This service is a covered benefit of Medicare and the Health Plan. Under Medicare rules, this means that these services are considered approved by the Health plan. While codes 98943 and 97032 are not covered benefits, the Plan has not provided evidence to dispute your argument that you never received services with the contracted provider on September 13, 2019.
Medical records are required in this case to prove that the contracted provider did provide the services at issue.
It is the burden of the Medicare Health Plan to substantiate the denial with evidence. Without medical records,
the Plan denial is not substantiated, and we must find in your favor. Therefore, we decided that the Plan must
hold you harmless for the manual manipulative treatment (98941), the extra-spinal manipulative treatment
(98943), and the electrical stimulation therapy (97032) provided on September 13, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean ultra-lightweight manual wheelchair.You asked the Plan to pre-approvemanual wheelchair. You say that the enrollee has a power wheelchair but needs a manual wheelchair to be used in the community.The Plan denied your request.The Plan says the denial of authorization for this item is correct, because the enrollee already has a power wheelchair for use in the home and this item is not covered for use outside of the home.The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home. The enrollee has already received a wheelchair for use within the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home.Therefore, we decided that the Plan does not have to pre-approvean ultra-lightweight manual wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean under the bed grab bar.You asked the Plan to pre-approvean under the bed grab bar. You say that the enrollee has a severe condition and needs this grab bar for his bed.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan covers all items that Medicare covers. Medicare rules state that grab bars are not covered because they are not primarily medical in nature. While a grab bar 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-approvean under the bed grab bar.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe surgical removal of an erupted tooth for teeth # 3, 4, 5, 6, 7, 8, 10, and 11, and the surgical removal of remaining tooth roots covered by bone for tooth # 9.You asked the Plan to pre-approvethe dental services. You say that the enrollee's teeth are rigid and causing her paid. You say that they are a choking hazard because the enrollee is not able to chew her food. You say that the enrollee cannot get dentures if she still has teeth in her mouth. You also say that the surgical extractions are medically necessary.The Plan denied your request. The Plan says surgical extractions are not covered 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 requested surgical extractions are not among those covered under this benefit. The Evidence of Coverage clearly states that only simple extractions are a covered by the Plan.Therefore, we decided that the Plan does not have to pre-approvethe surgical removal of an erupted tooth for teeth # 3, 4, 5, 6, 7, 8, 10, and 11, and the surgical removal of remaining tooth roots covered by bone for tooth # 9.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvethe bone grafting and guided tissue regeneration described by codes D4263 and D4266.You asked the Planto pre-approvethe gum surgery services. You say that the specialist who evaluated you feels that these services are necessary and you feel it should be covered by the Plan.The Plandenied your request. The Plansaysyour dental benefit does not include coverage for these 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 requested items or services are not among those covered under this benefit.Therefore, we decided that the Plandoes not haveto pre-approvethe bone grafting and guided tissue regeneration described by codes D4263 and D4266.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have topre-approvea power scooter.You asked the Plan to pre-approvethese services. You say that you would like an outdoor terrain scooter.The Plan denied your request. The Plan says the item is not covered.The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home.Therefore, we decided that the Plan does not have to pre-approvea power scooter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvefoot orthotics.You asked the Plan to pre-approvefoot orthotics. You say that the orthotics would help you be more self-sufficient.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 orfor 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-approvefoot orthotics.
Appeal type: Imaging
Decision: Favorable

We decided that the Planhasto pre-approvethyroid imagingYou asked the Planto pre-approvethe imaging. You say that this is medically necessary.The Plandenied your request. The Plansaysthatthe services were not considered medically necessary.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review thecase file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the imaging. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found your TSH level was last measured on 10/21/19 and was 0.136 (low normal) but had decreased from 0.272 a month earlier. The T4 level was normal at 1.1, making the possibility of subacute hyperthyroidism unlikely but still possible in light of the decreasing TSH level. It would seem reasonable to approve a thyroid ultrasound screen for nodules and for thyroid consistency and size prior to analyzing thyroid uptake and scan. It would also seem reasonable to repeat the TSH level prior to authorizing uptake and scan especially since it was decreasing in the fall of 2019 but has not been measured since.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 imaging have been met.Therefore, we decided that the Planhas to pre-approvethyroid imagingIf the Plandoes 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/orsend us the new information. This does not happen often. If we decide toopen the case again, we will send you a letter.