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

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) provided on November 20, 2019.
You asked the Plan to pay for the dental service. You say that you were not informed that the service rendered on February 21, 2019 would be billed as an exam. You say that you were not informed that it would affect your frequency limitations for the benefit year. You also say that you are not able to pay the bill. The Plan denied your request. The Plan says 2 oral exams are covered per calendar year. The Plan also says the frequency limit has been exceeded.
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 and oral exams are a covered service, the frequency limit has been exceeded. The record shows that the Plan paid for oral exams that you received on February 21, 2019 and May 20, 2019. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120) provided on November 20, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for sales tax (S9999).
You asked the Plan to pay for sales tax. You say that you would like to appeal the denial of the claim for the walker that was purchased over the counter at for the 80% reimbursement request due to incorrect information given by several representatives. The Plan denied your request. The Plan says sales tax is included in the cost of the item and not separately reimbursable.
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, we have confirmed that code S9999 has a bundled relationship with the purchased item and cannot be paid as billed. This code cannot be paid as a separate line item. Based on this information, we decided that the Plan does not have to pay for sales tax (S9999).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient office visit provided to the enrollee on October 29, 2019.
You asked the Plan to pay for outpatient services. You say that the claim should be paid. The Plan denied your request. The Plan says during the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on October 3, 2019. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for outpatient office visit provided to the enrollee on October 29, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided on November 11, 2019.
You asked the Plan to pay for the dental services. You say that you have been going to the same provider for 9 years. You say that you normally receive partial reimbursement for services from this provider. You say that the cleaning should be covered under your regular insurance. You also say that you should not have to pay a separate premium for this service. The Plan denied your request. The Plan says provider in this case has opted out of Medicare. The Plan also says that the services provided by a dentist who has opted out of Medicare are not payable.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation. The provider in this case has opted out of the Medicare program. The file shows that the provider in this case has entered into a private contract with you regarding payment. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided on November 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit, impression for mouth splint, and oral appliance 
You asked the Plan to pre-approve an office visit, impression for mouth splint, and oral appliance. You say that the enrollee needs treatment for TMJ. The Plan denied your request. The Plan says any treatment related to TMJ is not covered by Medicare under any condition.
The Plan must follow Medicare rules. The rules say that Medicare covers treatment for TMJ syndrome only when the condition or symptom is medical in nature. The treatment must also be medically reasonable and necessary. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an office visit, impression for mouth splint, and oral appliance have not been met. Therefore, we decided that the Plan does not have to pre-approve an office visit, impression for mouth splint, and oral appliance
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve the SNF admission. You say that you have a long way to go with therapy
and you are certain the facility could help you get stronger so you could live a better life. The Plan denied your
request. The Plan says SNF admission is not medically necessary and the enrollee's therapy needs can be
provided at a lower level of care such as home health care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above 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 the SNF admission. Our reviewer says
that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled
nursing service needs. The enrollee does have skilled therapy service needs but does not require skilled therapy
on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient
basis in a skilled nursing facility setting.
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 SNF admission have not been met. Therefore, we decided that the Plan does
not have to pre-approve the skilled nursing facility (SNF) admission.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), the bitewing x-rays (D0274) and the cleaning (D1110) provided on December 10, 2019.
You asked the Plan to pay for the periodic oral evaluation (D0120), the bitewing x-rays (D0274) and the cleaning (D1110). You say that you were not aware that you were approaching to exceed your yearly dental maximum. The Plan denied your request. The Plan says you have exceeded your maximum benefit 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. Though the Plan offers a dental benefit in excess of Medicare coverage, there is a benefit limit for the annual maximum. The plan clearly states that after the annual maximum is exhausted, any remaining charges are your responsibility. The records show the annual maximum was met on June 24, 2019 which exhausted the benefit. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120), the bitewing x-rays (D0274) and the cleaning (D1110) provided on December 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physiologic studies of arteries (93923 and 93922) and autonomic nervous system function testing (95921 and 95923) provided on May 21, 2019.
You asked the Plan to pay for the testing services. You say that you would like reconsideration because this testing was medically necessary. The Plan denied your request. The Plan says the testing services were 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 pay for the testing services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not include a detailed or abnormal findings on physical examination. The enrollee is not on blood pressure medication and has a normal blood pressure reading. The provider did not include a differential diagnosis or outline clinical concern. 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 testing services have not been met. Therefore, we decided that the Plan does not have to pay for physiologic studies of arteries (93923 and 93922) and autonomic nervous system function testing (95921 and 95923) provided on May 21, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a complete series of intraoral radiographic images (D0210) provided on November 18, 2019.
You asked the Plan to pay for a complete series of intraoral radiographic images. You say that you were told this would be covered. The Plan denied your request. The Plan says this is not covered by Medicare or the 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, 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 a complete series of intraoral radiographic images (D0210) provided on November 18, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the additional skilled nursing care.
You asked the Plan to pre-approve the additional skilled nursing care. You say that you are worried if you are sent away from the SNF that your wound could become infected. You also say that you were told that your bladder problems are caused by the kidney and you will need hospital care for that. The Plan denied your request. The Plan says Skilled Nursing Facility (SNF) care beyond 100 days per benefit period is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. The file shows that you received 100 days of SNF care during the benefit period from November 29, 2019 to March 7, 2020. The Plan has covered 100 days of SNF care. Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. You will be eligible for a new benefit period when you have not been receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the Plan does not have to pre-approve the additional skilled nursing care.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay forintraoperative neurophysiology monitoring (95941) and train of four testing (95999)provided on June 11, 2019.You asked the Plan to pay forintraoperative neurophysiology monitoring and train of four testing. You say that these codes are recognized as separate, distinct services an should be paid.The Plan denied your request. The Plan says these codes are not valid as billed.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 find that CPT codes 95941 and 95999 are not supported in the medical record. Specifically, 95941 has a status indicator of "I." Medicare uses another code for reporting of, and payment for these services. Theuse of unlisted CPT code 95999 to report train of four testing isalsonot supported. According to CPT coding rules, train of four testing is not a separately reportable procedure and is included in the other interoperative neuromonitoring procedures.Based on this information, we decided that Medicare rules for coverage of intraoperative neurophysiology monitoring and train of four testing have not been met. Therefore, we decided that the Plan does not have to pay forintraoperative neurophysiology monitoring (95941) and train of four testing (95999) provided on June 11, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a frenulectomy, an alveoloplasty for all 4 quadrants, 8 surgical extractions, and the surgical removal of tooth roots for 7 teeth.
You asked the Plan to pre-approve the dental services. You say that you are having issues with eating and talking. You say that you are in pain from the cavities. You also say that you are worried that if you do not get these services done then it could lead to further medical issues. The Plan denied your request. The Plan says the requested dental services are not listed as 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, the requested dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a frenulectomy, an alveoloplasty for all 4 quadrants, 8 surgical extractions, and the surgical removal of tooth roots for 7 teeth.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a genicular nerve block.
You asked the Plan to pre-approve the block. You say that this is medically necessary. The Plan denied your request. The Plan says medical studies have not proven that this service is helpful for treatment of your health problem.
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 block. Our reviewer says that the requested block is not considered medically reasonable and necessary in this case. Our physician reviewer found this is an experimental/investigational procedure and as such, is deemed not medically reasonable or 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 block have not been met. Therefore, we decided that the Plan does not have to pre-approve a genicular nerve block.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the compression stockings identified with code A6549 that were issued on October 23, 2019.
You asked the Plan to pay for the compression stockings. You say that you were told that the compression stockings would be covered as they were required after surgery. The Plan denied your request. The Plan says the compression stockings are noncovered.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression stockings identified with code A6549 that were issued on October 23, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve trigger point injections.
You asked the Plan to pre-approve the injections. You say that you would like reconsideration because the injections are medically necessary. The Plan denied your request. The Plan says there is no documentation of Pulmonary Embolism or other conservative measures used/trialed or failed to support the medical necessity of this procedure.
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 injections. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found a comprehensive history and physical examination was not conducted to diagnose myofascial pain prior to the injections. There was no documentation of conservative treatment with pain medications, exercises or non- pharmacological modalities. Since history and physical examination were not documented and the member had not failed conservative therapy, the requested trigger point injections were not medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the injections have not been met. Therefore, we decided that the Plan does not have to pre-approve trigger point injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a retreatment of previous root canal therapy (D3347), surgical procedure for isolation of tooth with rubber dam (D3910), and canal preparation and fitting of preformed dowel or post (D3950).
You asked the Plan to pre-approve the retreatment of previous root canal therapy, surgical procedure for isolation of tooth, and canal preparation and fitting of preformed dowel or post. You say that you have the right to get a root canal. You also say that you think this is undergoing the same treatment again. The Plan denied your request. The Plan says these services are not 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, 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 retreatment of previous root canal therapy (D3347), surgical procedure for isolation of tooth with rubber dam (D3910), and canal preparation and fitting of preformed dowel or post (D3950).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF admission and services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that the enrollee is not safe to return to his home. The Plan denied your request. The Plan says the enrollee's needs at this time are considered custodial.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 services. Our physician reviewer found that from a nursing perspective, the enrollee had stable vital signs, and his lungs were clear. There are no identifiable skilled nursing service needs. Regarding rehab services, the enrollee was at a standby assist to contact guard assist level with functional mobility. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF setting. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that you need a shower chair. The Plan denied your request. The Plan says this item is not a covered benefit.
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 a shower chair.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hydroxine Hcl for the enrollee.
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered 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 drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Hydroxine Hcl for the enrollee.
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eliquis for the enrollee.
You asked the Plan to pre-approve this drug. The Plan denied your request. The Plan says that this is not covered 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 drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Eliquis for the enrollee.
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.