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

We decided that the Plan does not have to pay for the incisional biopsy of oral tissue-soft (D7286) provided February 3, 2021.

You asked the Plan to pay for the soft tissue biopsy. You say that you believe this should be covered as a medically necessary service. The Plan denied your request. The Plan says this service is not covered under your 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 incisional biopsy of oral tissue-soft (D7286) provided February 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the complete upper denture (D5110).
You asked the Plan to pre-approve the complete upper denture (D5110). You say that you have a rat infestation and the rats took your top denture. You say that you need a replacement. The Plan denied your request. The Plan says this service is limited to only one procedure every five plan years.
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, you also have a maximum benefit of one complete upper denture every five plan years. The Plan paid for a complete upper denture provided on April 6, 2021, which exhausted your benefit. Therefore, we decided that the Plan does not have to pre-approve the complete upper denture (D5110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a surgical placement of an implant (D6010).
You asked the Plan to pre-approve a surgical placement of an implant. You say that the service at issue is medically necessary. The Plan denied your request. The Plan says the service at issue 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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a surgical placement of an implant (D6010).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal scaling and root planing - four or more teeth per quadrant (D4341).
You asked the Plan to pre-approve periodontal scaling and root planing. You say that this service is medically necessary. The Plan denied your request. The Plan says this service is not covered under the enrollee's 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 pre-approve
periodontal scaling and root planing - four or more teeth per quadrant (D4341).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient treatments provided from February 5, 2020, to February 13, 2020.
You asked the Plan to waive the copayment for the outpatient treatments. You say that the bill was reprocessed and now you owe more. The Plan denied your request. The Plan says you have been asked to pay 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 $350 copayment for each Medicare-covered non-surgical visit in an outpatient clinic after you meet your $250 deductible.
You have been asked to pay a $187. 34 copayment for the outpatient treatments. The outpatient treatments fall within the "Outpatient hospital services" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the outpatient treatments provided from February 5, 2020, to February 13, 2020.
Your complaint about the billing error is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.
You asked the Plan to pre-approve the continuous glucose monitor. You say that the continuous glucose monitor is medically necessary due to limited dexterity. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of the continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial lower denture (D5214) and a crown (D2740) and core buildup (D2950) for tooth #24 and tooth #25.
You asked the Plan to pre-approve the dental services. You say that these services are necessary and should be covered. The Plan denied your request. The Plan says the type of crown and core buildup requested are not covered by your dental benefits. The denture is a covered service; however, it cannot be pre-approved in this case because the Plan provided a lower denture for you less than five years ago. Dentures can only be covered once per arch every five years. Therefore, the services remain denied.
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 or are requested in a frequency that exceeds what is covered by the benefit. Documentation shows that the Plan paid for a partial lower denture in June of 2018, which is less than five years before the date of this request. Therefore, we decided that the Plan does not have to pre-approve a partial lower denture (D5214) and a crown (D2740) and core buildup (D2950) for tooth #24 and tooth #25.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve positron emission tomography (PET) with concurrently
acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; skull base
to mid-thigh.
You asked the Plan to pre-approve the PET/CT scan. You say that the PET scan is needed to make sure there is
no nodule involved and in order to make a proper treatment plan. The Plan denied your request. The Plan says
the requested PET scan is not supported by the first staging of prostate cancer.
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 PET/CT scan. Our reviewer says
that the requested PET/CT scan is not considered medically reasonable and necessary in this case. Our
physician reviewer found Axumin is approved for men with suspected prostate cancer recurrence based on
rising PSA. It is not approved for initial staging.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the PET/CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; skull base to mid-thigh
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 you need rehabilitation to recover from your injuries. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.
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 complexity of your nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While you do require physical and occupational therapy, there is no documented need for an intensive rehabilitation program.
Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that you 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the brace provided on March 8, 2021.
You asked the Plan to waive the coinsurance for the brace. You say that you were told that the brace would be covered at no cost. The Plan denied your request. The Plan says you have been asked to pay 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 20% coinsurance for prosthetic devices and medical supplies. You have been asked to pay $167.43 which is 20% of the allowed amount for the brace. The allowed amount is $837.16. ($837.16 x 20% = $167.43). The brace falls within the "Prosthetic devices and related supplies" benefit category.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the brace provided on March 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Exogen Ultrasound Bone Growth Stimulator (E0760).

You asked the Plan to pre-approve the bone growth stimulator. You say that the enrollee has extenuating circumstances that necessitate the bone growth stimulator. The Plan denied your request. The Plan says coverage is only indicated for nonunion of long bone fractures with two sets of radiographs "separated by a minimum of 90 days."

The Plan must follow Medicare rules. Medicare rules say that the nonunion of a fracture must be documented by a minimum of two sets of radiographs obtained prior to starting treatment with the osteogenesis stimulator, separated by a minimum of 90 days. The documentation does not contain two sets of radiograms, separated by 90 days.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the bone growth stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve an Exogen Ultrasound Bone Growth Stimulator (E0760).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the complete upper and lower denture (D5110 and D5120).
You asked the Plan to pre-approve the complete upper and lower denture (D5110 and D5120). The Plan denied your request. The Plan says the services are not covered 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 pre-approve the complete upper and lower denture (D5110 and D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a custom fabricated abutment (D6057) for tooth #5 and
#7.
You asked the Plan to pre-approve the abutments. You say that these services were previously covered by this
enrollee's dental Plan, and they are necessary in this case. However, the enrollee had a previous surgery that
required healing time, and between that and the pandemic lockdown, they were unable to have the services
when they were covered by the Plan. The Plan denied your request. The Plan says they have agreed to cover
the requested implant supported crowns (D6065) for these teeth; however, it is inappropriate for the two
requested services to be provided together. D6057 is an abutment that is placed in preparation for an abutment
supported crown. Since D6065 has already been approved, these teeth will be restored with implant supported
crowns.
There is no indication that an abutment is needed. If an abutment was needed, a request for an abutment
supported crown would have been more appropriate, as an implant supported crown does not require an
abutment.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a
custom fabricated abutment (D6057) for tooth #5 and #7.
Your request for approval of services that were previously covered by the Plan is not a valid appeal for medical
coverage. This part of your complaint is a grievance that must be answered by the Plan. It appears that the Plan
has approved part of your request through a grievance process; however, Medicare does not permit us to make
a decision about these types of complaints.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the records provided support the need for care in an IRF. The Plan denied your request. The Plan says IRF care is not medically necessary. The Plan says that the enrollee's needs can be met in a lower level of care.
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 complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for syncope and hyponatremia after recent surgical repair of a tibia fracture. She has been discharged home with home health services and has ongoing weakness. The enrollee's medical conditions are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The enrollee 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. There is not a reasonable expectation that this enrollee 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 pre-approve a resin-based composite - three surfaces, anterior (D2332), resin-based composite - four or more surfaces or involving incisal angle (anterior) (D2335), resin-based composites - three surfaces, posterior (D2393), and periodontal scaling and root planing - four or more teeth per quadrant (D4341).
You asked the Plan to pre-approve resin-based composites and periodontal scaling and root planing. You say that your dentist has recommended the services as necessary to avoid worsening of your medical conditions. The Plan denied your request. The Plan says you have exceeded frequency limits for the resin-based composites and the periodontal scaling and root planing is not a covered service.
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 one resinbased
composite per year.
We looked at the file and Medicare rules. The Plan provided documentation showing that a resin-based
composite was previously covered on June 22, 2021. Based on this information, we determined that the Plan's
frequency limit for resin-based composites would be exceeded with the requested services. Though the Plan
provides dental benefits in excess of Medicare coverage, periodontal scaling and root planing is not among
those covered services. Therefore, we decided that the Plan does not have to pre-approve a resin-based
composite - three surfaces, anterior (D2332), resin-based composite - four or more surfaces or involving incisal
angle (anterior) (D2335), resin-based composites - three surfaces, posterior (D2393), and periodontal scaling
and root planing - four or more teeth per quadrant (D4341).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a standard wheelchair (K0001).
You asked the Plan to pre-approve the wheelchair. You say that the wheelchair is medically necessary. The Plan denied your request. The Plan says a power wheelchair has already been provided to meet the enrollee's mobility needs.
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 a power wheelchair. A power wheelchair serves the same purpose as the wheelchair. Therefore, we decided that the Plan does not have to pre-approve a standard wheelchair (K0001).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Intracept procedure.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the requested Intracept procedure is experimental in nature for the treatment of low back pain. More research is needed to show safety and efficacy. The services are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve an Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve group 3 power mobility device features (E2300, E2311, E2377, E2313).

You asked the Plan to pre-approve power mobility device features. You say that the features are necessary. The Plan denied your request. The Plan says these features are noncovered.

The Plan must follow Medicare rules. Medicare rules say that power seat elevation feature (E2300) and power standing feature (E2301) are non-covered because they are not primarily medical in nature. The Expandable Controller (E2377), Expandable Controller Harness (E2313) and Electro Connect Btw 2 Sys Electro Connect Btw 2 Sys (E2311) are requested to control power tilt, recline and power elevating leg rests through the joystick. Although there are three approved power options on this wheelchair (tilt, recline and elevating leg rests), there is not a medical need shown in the documentation to control these power options through the joystick. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of power mobility device features have not been met. Therefore, we decided that the Plan does not have to pre-approve group 3 power mobility device features (E2300, E2311, E2377, E2313).