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

We decided that the Plan does not have to pay for periodontal maintenance (D4910) and fluoride treatment (D1208) provided on December 10, 2019.
You asked the Plan to pay for the dental services. You say that you are requesting an appeal because your dentist says that you need your teeth cleaned every 3 months. The Plan denied your request. The Plan says the requested services exceeds the plan's benefit frequency limit.
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 contract specifically says that periodontal maintenance and fluoride treatment is covered 2 time per plan year. 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 periodontal maintenance (D4910) and fluoride treatment (D1208) provided on December 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 6, 2019 by an out of network (OON) provider.
You asked the Plan to pay for these OON services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
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 the medical services provided on August 6, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for neuroplasty (64721) provided on November 6, 2019.
You asked the Plan to pay for the neuroplasty. You say that you would like reconsideration because the assistant surgeon was chosen by the operating surgeon and could not deny the services. The Plan denied your request. The Plan says the services of an assistant surgeon, co-surgeon or surgical team are not covered for this procedure.
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for CPT code 64721. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the neuroplasty have not been met. Therefore, we decided that the Plan does not have to pay for neuroplasty (64721) provided on November 6, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the patient is medically appropriate for the LTACH care and there is a need for transfer so that the community hospital can be prepared for Covid 19 patients. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of a LTACH admission.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that the patient is currently undergoing treatment at an acute care hospital (ACH) for osteomyelitis of his left foot. The enrollee has undergone surgical debridement and a toe amputation. The enrollee continues to receive wound care and a prolonged course of antibiotics. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long-term care needs. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pre-approve a surgical nasal/sinus endoscopy for the enrollee.
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says that there was not enough evidence found to support this procedure.
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 the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the procedure. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found CPT 31295 is the code for sinus endoscopy with balloon dilation of the maxillary sinus. CPT 31298 is for sinus endoscopy with dilation of the frontal and sphenoid sinuses. The enrollee meets criteria for a balloon sinuplasty, therefore he meets criteria for both CPT codes. The procedure itself has become a validated treatment option for patients suffering from chronic sinusitis and recurrent acute sinusitis. He suffers from chronic sinusitis refractory to medical treatment. He has nasal drainage, congestion, and pain/pressure. He has tried multiple appropriate medical treatments and has not improved. His CT scan shows clear evidence of chronic sinusitis. Given that his disease of chronic sinusitis has not improved, proceeding with surgical management is indicated and reasonable. 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 procedure have been met. Therefore, we decided that the Plan has to pre-approve a surgical nasal/sinus endoscopy for the enrollee.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vitamin C infusion therapy (Vitamin C.1.V 75) and Methyl B12 plus sublingual 90T provided November 27, 2019 to December 5, 2019.
You asked the Plan to pre-approve Vitamin C infusion therapy and Methyl B12 plus sublingual 90T. You say that this treatment stopped the growth of her cancer. 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 Vitamin C infusion therapy and Methyl B12 plus sublingual 90T. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the records show that in June, you inquired about several holistic treatments that you recently read about. Your provider discussed that the treatment requested is not standard of care at their office, and that such treatment would not be prescribed. The records do not show a medical indication for these services. The documentation does not support that the Vitamin C infusion therapy (Vitamin C.1.V 75) and Methyl B12 plus sublingual 90T are medically reasonable and necessary for you 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 Vitamin C infusion therapy and Methyl B12 plus sublingual 90T have not been met. Therefore, we decided that the Plan does not have to pre-approve Vitamin C infusion therapy (Vitamin C.1.V 75) and Methyl B12 plus sublingual 90T provided November 27, 2019 to December 5, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the refraction provided on December 11, 2019.
You asked the Plan to pay for the refraction. You say that you were not told you would have to pay for this test. The Plan denied your request. The Plan says that the second exam was denied correctly.
Medicare 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. The Plan covers one routine eye exam (eye refraction exam) per calendar year. We looked at the file and the Plan's rules. The file indicates that the Plan provided coverage for a refraction on May 22, 2019. Based on this information, we decided that the Plan's rules for coverage of the refraction have not been met. Therefore, we decided that the Plan does not have to pay for the refraction provided on December 11, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve gingival irrigation (D4921) for the lower right quadrant, periodontal scaling and root planing for 1 to 3 teeth per quadrant (D4342) for the lower left and lower right quadrants, and core build up (D2950) for teeth # 22, 27, 28 and 29.
You asked the Plan to pre-approve gingival irrigation, periodontal scaling and root planing, and core build up. You say that there is pulp exposure. You also say that the requested crown is necessary afterwards to prevent fracture. The Plan denied your request. The Plan says gingival irrigation, periodontal scaling and root planing for 1 to 3 teeth per quadrants, and core build up are not listed as 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 dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve gingival irrigation (D4921) for the lower right quadrant, periodontal scaling and root planing for 1 to 3 teeth per quadrant (D4342) for the lower left and lower right quadrants, and core build up (D2950) for teeth # 22, 27, 28 and 29.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the endoscopy and a colonoscopy provided on October 18, 2019.
You asked the Plan to waive the copayment for the endoscopy and the colonoscopy. You say that you were told multiple times you would be fully covered with no copayments. You say you are on a fixed income and cannot afford the copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $0 copayment or $125 copayment for each Medicare-covered ambulatory surgical center visit. $0 copayment for any surgical procedures (i.e., polyp removal) during a colorectal screening. $125 copayment for all other Ambulatory Surgical Center (ASC) services. You have been asked to pay a $125 copayment for the endoscopy. The endoscopy and the colonoscopy fall within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows you were not charged for the colonoscopy.
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 the endoscopy and a colonoscopy provided on October 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a custom fabricated abutment (D6057) and an implant supported crown (D6066) for tooth # 29.
You asked the Plan to pre-approve the dental services. You say that Implant # 29 was placed last year and covered by the enrollee's plan. You say that it is in need of an abutment and crown. You say that the implant will soon experience bone loss, pain and infection overtime, and eventually lead to surgical removal of the implant that can result in additional pain for the enrollee. The Plan denied your request. The Plan says the custom abutment and implant supported crown are not listed as covered services. The Plan says the implant procedure was performed in December 2018. The Plan says complete for these services is between 3 to 4 months. The Plan also says that you waited over 1 year to continue these services and therefore do not full under continuation of care.
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 custom fabricated abutment and implant supported crown are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a custom fabricated abutment (D6057) and an implant supported crown (D6066) for tooth # 29.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power scooter.
You asked the Plan to pre-approve these services. You say that your current power wheelchair has low battery and dies before you get down the street. The Plan denied your request. The Plan says the item is not covered.
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 rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The file shows that you have a power wheelchair that serves the same purpose as the requested power scooter. Furthermore, the file shows that you are requesting the power scooter for use outside of the home and Medicare does not cover this item for that purpose. Therefore, we decided that the Plan does not have to pre-approve a power scooter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve the IRF care. You say that the inpatient rehabilitation facility admission is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an inpatient rehabilitation facility admission.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 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 that the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require, or to be able to perform, fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's needs can be met at a lower level of care. 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a motorized scooter.
You asked the Plan to pre-approve a scooter. You say that you can no longer push the manual wheelchair. The Plan denied your request. The Plan says there is no home evaluation or specialty evaluation.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The file does not show that the enrollee can safely operate the PMD being requested. There is no home assessment to verify the enrollee can adequately maneuver a scooter in the home. There is no specialty evaluation to document the medical necessity for a scooter. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a motorized scooter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Functional electrical stimulator (FES) (E0770).
You asked the Plan to pre-approve Functional electrical stimulator (FES). You say that you strongly disagree with the conclusion of by the plan and request reconsideration of this determination. The Plan denied your request. The Plan says the records do not support the requested service is medically necessary.
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 Functional electrical stimulator (FES). 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 the enrollee's issues with his hand are due to a prior stroke, which would imply that the nerve supply to the muscle is intact would not be satisfied (given that the stroke would have caused neurological insult that led to the resulting condition). Consequently the requested item would not meet the Medicare requirements for coverage and would not meet the definition of being 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 Functional electrical stimulator (FES) have not been met. Therefore, we decided that the Plan does not have to pre-approve Functional electrical stimulator (FES) (E0770).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea power wheelchair (K0835).You asked the Plan to pre-approvea power wheelchair. You say that you needthis due to your knees locking and being in pain.The Plan denied your request. The Plan says this is not necessary because you are able to use a walker.The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The file shows that your condition can be improved by a walker, cane or manual wheelchair. The submitted medical records show that you were evaluated and able to ambulate sufficiently with your current walker. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approvea power wheelchair (K0835).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator from an out of network provider.
You asked the Plan to pre-approve a home ventilator from an out-of-network provider. You say that the enrollee needs a home ventilator. The Plan denied your request. The Plan says they agree a home ventilator is medically necessary but it is available in-network.
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 at issue in this appeal. We found no exception that would require the Plan to pre-approve this item. Therefore, we decided that the Plan does not have to pre-approve a home ventilator from an out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power wheelchair repairs.
You asked the Plan to pre-approve power wheelchair repairs. You say that without repairs your wheelchair will stop working. The Plan denied your request. The Plan says that repairs are not covered because they exceed the cost of the wheelchair.
The Plan must follow Medicare rules. Medicare rules say that that if the expense for repairs exceeds the estimated expense of purchasing or renting another item of equipment for the remaining period of medical need, no payment can be made for the amount of the excess. We looked at the file and Medicare rules. The Plan approved and paid for a power wheelchair and power wheelchair repairs. You received a power wheelchair in May 2017 and repairs have been performed. The repairs of the power wheelchair have exceeded the cost of the power wheelchair. The additional repairs are not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of power wheelchair repairs have not been met. Therefore, we decided that the Plan does not have to pre-approve power wheelchair repairs.