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

 
We decided that the Plan does not have to pay for six extractions, erupted tooth requiring removal of bone 
and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210) provided on 
July 27, 2020. 
 
You asked the Plan to pay for seven extractions, erupted tooth requiring removal of bone and/or sectioning of 
tooth, and including elevation of mucoperiosteal flap if indicated. You say that the service is medically 
necessary. The Plan denied your request. The Plan says the services do not meet the criteria for coverage under 
the medical 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. The Plan covers one extraction 
per a lifetime. 
 
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. Specifically, you received seven extractions, the Plan only allows one 
extraction. This means you are responsible for the other six extractions. Therefore, we decided that the Plan 
does not have to pay for six extractions, erupted tooth requiring removal of bone and/or sectioning of tooth, and 
including elevation of mucoperiosteal flap if indicated (D7210) provided on July 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Combigan eye drops.
You asked the Plan to pre-approve Combigan eye drops. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee has a medical only policy which does not include Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been met.
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 Combigan eye drops.
Benefits for Combigan eye drops 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve spinal cord stimulation (SCS) (63650).
You asked the Plan to pre-approve SCS. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that SCS may be covered for certain circumstances. 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 SCS. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has no evidence based indication for a SCS trial. The request is 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 SCS have not been met. Therefore, we decided that the Plan does not have to pre-approve spinal cord stimulation (SCS) (63650).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on May 22, 2020 by an out of network 
(OON) provider. 
 
You asked the Plan to pay for the medical 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 provided were neither emergent nor urgent and prior 
authorization was not obtained to provide out-of-network care. 
 
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 May 22, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient hospital 
setting from July 21, 2020, to July 22, 2020. 
 
You asked the Plan to pay for the self-administered drugs. You say that the drugs are medically necessary. The 
Plan denied your request. The Plan says self-administered drugs are not a covered benefit. The Plan says that 
self-administered drugs are not covered under Medicare Part B. The Plan also says no adjustment will be made 
to the claim. 
 
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 pay for the self-administered drugs 
provided in an outpatient hospital setting from July 21, 2020, to July 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean Invacare Tracer IV wheelchair and hi profile Roho cushion (E2622).You asked the Plan to pre-approvean Invacare Tracer IV wheelchair and hi profile Roho cushion. You say that the items are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. Medicare rules say that MA plans may specify brands and manufacturers as preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred brands and manufacturers, as long as specific conditions are met.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an Invacare Tracer IV wheelchair and hi profile Roho cushion have not been met.Therefore, we decided that the Plan does not have to pre-approvean Invacare Tracer IV wheelchair and hi profile Roho cushion (E2622)
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waivethe coinsurance charged for wheelchair accessories billed on August 3, 2020.You asked the Plan to waivethis coinsurance. You say that you have not received these items. You say that you receiveda wheelchair a year ago but did not get a bill.The Plan denied your request. The Plan says this cost share was applied based on the Plan contract agreement and the claim submitted by the provider.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 durable medical equipment. 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 waivethe coinsurance charged for wheelchair  accessories billed on August 3, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit services provided on March 
26, 2020. 
 
You asked the Plan to waive the copayment for the office visit services. You say that you feel you should not 
be responsible for this cost share amount and you would like the Plan to reconsider your request.  The Plan 
denied your request. The Plan says you had office visit services on the date of service at issue in this appeal. 
The Plan says that the correct copayment has applied per your contract with the Plan. 
 
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 $10 
copayment for Physician/Practitioner services.
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received office visit 
services on March 26, 2020. You have been asked to pay a $10 copayment for the office visit services. The 
office visit services fall within the Physician/Practitioner 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 office visit services provided on March 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse the full amount for the oral exam (D0120), prophylaxis 
(D1110), the bitewing x-rays (D0274), and unspecified preventive service (D1999) provided on August 20, 
2020. 
 
You asked the Plan to reimburse the full amount for the dental services. You say that you were under the 
impression that $25 would be deducted from each service and the remaining amount would be reimbursed. You 
say that you should be reimbursed an additional $47. The Plan denied your request. The Plan says the provider 
in this case is not a network provider. The Plan says if you use an out of network provider, your share of the 
costs for your covered services may be higher. The Plan also says that bitewing x-rays are 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, dental services that you receive out of 
network may have a higher cost share amount.  
 
 
 
 
 
CPT Code Billed Allowed Plan Paid OON Copayment Your Responsibility 
D0120 $61 $38 $13 $25 $48 
D1110 $95 $71 $46 $25 $49 
D0274 $75 $75 $0 $0 $75 
D1999 $8 $8 $8 $0 $0 
TOTAL:   $67  $172 
 
Additionally, the bitewing x-rays are not among those covered under this benefit. Therefore, we decided that 
the Plan does not have to reimburse more for the oral exam (D0120), prophylaxis (D1110), the bitewing x-rays 
(D0274), and unspecified preventive service (D1999) provided on August 20, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen and pelvis.
You asked the Plan to pre-approve a CT scan of the abdomen and pelvis. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 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 a CT scan of the abdomen and pelvis. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee did have a CT of the abdomen and pelvis without contrast on October 5, 2020 which revealed no findings needing close follow-up. The rationale for another CT of the abdomen and pelvis following his clinic visit of October 27, 2020 is not present in the records provided. 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 CT scan of the abdomen and pelvis have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen and pelvis.
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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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 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. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approved seventeen (17) PT visits.
You asked the Plan to pre-approved the seventeen (17) PT visits. The Plan denied your request. The Plan says an additional seventeen (17) PT visits are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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-approved the seventeen (17) PT visits. Our reviewer says that skilled services are not medically necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that you have chronic pain syndrome and bilateral foot pain, as well as diabetes. Treatments have included electrical nerve stimulation and neuromuscular re-education, vasopneumatic treatment and subcutaneous injections of nutraceuticals. The plan approved 12 outpatient PT visits from August 25, 2020, through October 23, 2020. The Plan approved one additional visit to help finalize a home exercise program and to educate and reinforce the importance of continued adherence to the program. The documentation does not support that the requested seventeen (17) additional outpatient PT visits are medically reasonable and necessary as specific and effective therapy for your condition. The records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or for physical therapy and occupational therapy, by or under the supervision of a therapist. The specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration. 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 seventeen (17) PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approved seventeen (17) PT visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services with dental code D0140 provided on 
February 13, 2020. 
 
You asked the Plan to pay for dental code D0140. 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. 
 
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 code D0140 is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental services with 
dental code D0140 provided on February 13, 2020.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pre-approve an additional six (6) speech therapy sessions. 
 
You asked the Plan to pre-approve the additional six (6) speech therapy sessions. The Plan denied your request. 
The Plan says that speech therapy for communication problems is considered medically necessary when you 
need the skills of a speech therapist. Based on the clinical information provided to us you are competent in 
completing the iPad exercises on your own. The notes do not show you need the ongoing skills of a speech 
therapist. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 additional six (6) speech therapy 
sessions. Our reviewer says that additional six (6) speech therapy sessions is medically reasonable and 
necessary. Our physician reviewer found that the enrollee has demonstrated severe expressive language 
impairment. The enrollee's speech-language pathologist writes that while the enrollee is able to obtain therapy 
at home on the computer, this does not take the place of the skilled therapy she receives, directed by the input 
and knowledge of an experienced, skilled speech-language pathologist. Skilled therapy guided by a speech-
language pathologist is generally accepted as specific and effective therapy for aphasia. The records 
demonstrate that the unique skills of a professional therapist are required to safely and effectively provide 
treatment, that the services can be safely and effectively performed only by a therapist, or for physical therapy 
and occupational therapy, by or under the supervision of a therapist. The specialized skill, knowledge and 
judgment of a qualified therapist is required to establish, design and/or deliver a program to maintain the 
enrollee's current condition or to prevent or slow further deterioration. 
 
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 additional six (6) speech therapy sessions have been met. Therefore, we 
decided that the Plan has to pre-approve an additional six (6) speech therapy sessions.  
 
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the Doppler echocardiography's with CPT codes 93320 and 
93325 provided on March 24, 2020. 
 
You asked the Plan to pay for CPT codes 93320 and 93325. 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. 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 codes 
93320 and 93325 have a bundled relationship with code 93312 and cannot be paid as billed. These codes 
cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been 
met. Therefore, we decided that the Plan does not have to pay for the Doppler echocardiography's with CPT 
codes 93320 and 93325 provided on March 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Inogen portable oxygen concentrator. 
 
You asked the Plan to pre-approve the portable oxygen concentrator. You say that you require a specific 
oxygen concentrator that is lighter than the one you have. The Plan denied your request. The Plan says you 
already have the smallest portable oxygen concentrator 
 
The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet 
the criteria for home oxygen. While you meet coverage criteria for portable oxygen concentrator, which you 
have, there is no necessity indicated for an Inogen Portable Oxygen Concentrator.    
 
 
 
 
 
We looked at this review, the file, and Medicare rules. Based on this information, we decided that Medicare 
rules for coverage of an additional portable oxygen concentrator have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an ?Inogen? portable oxygen concentrator.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy provided on August 3, 2020.
You asked the Plan to waive the copayment for the colonoscopy. You say that you are being charged for the use of the facility. You say that this should be covered. The Plan denied your request. The Plan says the copayment 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). Your contract with the Plan clearly says that you must pay $100 per day for outpatient procedures and services, including but not limited to diagnostic and therapeutic endoscopy, and outpatient surgery performed in an outpatient hospital or ambulatory surgical center. You have been asked to pay a $100 copayment for the colonoscopy. The colonoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show that biopsies were taken during the colonoscopy, which is considered a surgical service. 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 colonoscopy provided on August 3, 2020.