Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a cervical lymphadenectomy (38724) and related procedures (36415, 41120, 42890, 80048, 82962, 85027, 85610, 85730, 86850, 86900, 86901, 87635, J0690, J2250, J2704, J3010, Q9968) provided on September 22, 2020 to September 24, 2020
You asked the Plan to pay for a cervical lymphadenectomy and related procedures. You say that this was medically necessary. The Plan denied your request. The Plan says this was an inpatient-only procedure billed as an outpatient procedure.
The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule.
The service at issue in this appeal was billed with CPT code 38724. This code is listed with a status indicator of "C" on Addendum B of the 2020 OPPS/ASC final rule. This means the service has been designated as "inpatient only", and therefore must be billed as part of an inpatient admission. The services at issue were billed as outpatient services. Therefore, we decided that the Plan does not have to pay for a cervical lymphadenectomy (38724) and related procedures (36415, 41120, 42890, 80048, 82962, 85027, 85610, 85730, 86850, 86900, 86901, 87635, J0690, J2250, J2704, J3010, Q9968) provided on September 22, 2020 to September 24, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an occlusal guard (D9944).
You asked the Plan to pre-approve the occlusal guard. You say that you need the night guard because every morning you experience pain in the back of your teeth. The Plan denied your request. The Plan says dental splints used to treat a dental condition are specifically excluded from coverage.
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 an occlusal guard (D9944).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composites (D2332) provided on March 17,
2021 and the crown (D2752) provided on March 25, 2021.
You asked the Plan to pay for the resin-based composites (D2332) and crown (D2752). You say that the care
was necessary because the teeth are the main anchors for your partial dentures. You say that your dentist said
insurance would pay 20%. 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 pay for the resinbased
composites (D2332) provided on March 17, 2021 and the crown (D2752) provided on March 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for acupuncture, without electrical stimulation, initial 15 minutes (97810) and acupuncture, without electrical stimulation, each additional 15 minutes (97811) for knee pain provided March 18, 2021 to March 19, 2021.
You asked the Plan to pay for the acupuncture services. You say that please reconsider the claim for payment based on medical necessity. The Plan denied your request. The Plan says acupuncture for knee pain is not covered under the Plan benefits.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case. We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, the diagnoses billed M25.561 - pain in right knee and M25.562 pain in left knee. Acupuncture for knee pain is not covered by the Plan. Only acupuncture for chronic low back pain is covered. Therefore, we decided that the Plan does not have to pay for acupuncture, without electrical stimulation, initial 15 minutes (97810) and acupuncture, without electrical stimulation, each additional 15 minutes (97811) for knee pain provided March 18, 2021 to March 19, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for laboratory services provided on January 27, 2021.
You asked the Plan to waive the deductible for laboratory services. You say that you were not advised that you would owe a deductible. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $250 deductible for laboratory services. You received laboratory services on January 27, 2021. The record shows that you had paid $0 toward the $250 deductible prior to receiving the services. Therefore, you are responsible to pay the allowed amount of $227.16. The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $250 deductible for laboratory services. This cost sharing is a contractual obligation that had not been met at the time laboratory services were received on January 27, 2021. Therefore, we decided that the Plan does not have to waive the deductible for laboratory services provided on January 27, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the home health services.
You asked the Plan to pre-approve the home health services. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 home health services. Our reviewer says that the service is not medically necessary. Our physician reviewer found the documentation does not support you are home bound and the documents do not show the need for skilled therapy services such as physical therapy or occupational therapy. 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 home health services have not been met. Specifically, you are not home bound and you do not require skilled therapy services. Therefore, we decided that the Plan does not have to pre-approve the home health services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on January 25, 2021, to February
8, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for physician services. You say that you should not have to pay anything. The Plan
denied your request. The Plan says these services were not referred by an in-network provider. The Plan says
that these services were rendered in an out-of-network facility.
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 had network providers
available who could have provided 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 physician services provided on January 25, 2021,
to February 8, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a blood glucose monitor with integrated voice synthesizer.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there is no visual impairment to require a talking glucometer. 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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record documents that the provider has indicated that the enrollee does not have visual impairment. The elements of the coverage rule are not satisfied. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve a blood glucose monitor with integrated voice synthesizer.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve shoe and heel lifts.
You asked the Plan to pre-approve foot orthotics. You say that you can't walk without this built-up shoe on the
bottom because the surgery shortened your leg. The Plan denied your request. The Plan says this item is not a
covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your
condition. Therefore, we decided that the Plan does not have to pre-approve shoe and heel lifts.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the computed tomography (CT) scan of the abdomen and pelvis and the related low osmolar contrast material you received on February 26, 2021.
You asked the Plan to waive the cost sharing for the CT scan and related low osmolar contrast material. You say that you think you should only have to pay a $40 copayment. The Plan denied your request. The Plan says you were charged this cost sharing 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 a $40 copayment for advanced imaging services and 20% coinsurance for Medicare Part B drugs You have been asked to pay a $40 copayment for the CT scan and 20% coinsurance for the related low osmolar contrast material. The CT scan falls within the advanced imaging services benefit category and the related low osmolar contrast material falls within the Medicare Part B drug benefit category. This means that you have been asked to pay the correct amounts 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 cost sharing for the computed tomography (CT) scan of the abdomen and pelvis and the related low osmolar contrast material you received on February 26, 2021.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF 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 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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found the documentation does not 
support the need for a therapy program consisting of at least 3 hours of therapy per day at least 5 days per 
week. While he may benefit from continued physical therapy and occupational therapy there is no evidence of 
need for an intensive therapy program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation care. IRF admission is not medically necessary based on lack of 
need for medical supervision by PM&R physician and skilled rehabilitation nursing needs and current 
functional level. 
 
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 pre-approve power wheelchair, group 3 standard, single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds (CPT code K0856) and accessories (CPT code(s): E2377, E1002, E1028, E2313, E0955, E1028, E1012, E2310, E2359, E2609, and E2617), for the enrollee.
You asked the Plan to pre-approve the DME. You say that the enrollee is severely disabled and requires requested equipment to be able to mobilize independently, perform their own pressure relief and improve their
quality of life. You state the wheelchair will accommodate their numerous postural deficits, lack of strength
and range of motion. The Plan denied your request. The Plan says the Medicare rules have not been met.
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 DME. Our physician reviewer
found the documentation does not reveal that the enrollee has the diagnostic criteria for a Group 3 power
wheelchair. The enrollee does not have a myopathy, congenital skeletal deformity, or neurological condition.
LCD: Power Mobility Devices (L33789) for the requested power wheelchair and accessories have not been
met.
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 DME have not been met. Therefore, we decided that the Plan does not have
to pre-approve power wheelchair, group 3 standard, single power option, sling/solid seat/back, patient weight
capacity up to and including 300 pounds (CPT code K0856) and accessories (CPT code(s): E2377, E1002,
E1028, E2313, E0955, E1028, E1012, E2310, E2359, E2609, and E2617), for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the computed tomography (CT) lumbar spine (72131).
You asked the Plan to pre-approve the CT scan. You say that the medical records provided support the necessity of the requested services. The Plan denied your request. The Plan says the enrollee does not meet the medically necessary coverage criteria.
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 the CT scan. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee is wearing a thoracic lumbar spinal orthosis brace and is improving. The plan is to repeat the CT scan prior to the next visit. The record does not indicate when the enrollee had his operation and what any previous CT scan demonstrated. The record provided does not support the /medical necessity or reasonableness, as defined by Medicare rules, of the requested service. 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 CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve the computed tomography (CT) lumbar spine (72131).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the gingival irrigations (D4921) and periodontal scalings and root planings (D4341) provided on April 26, 2021, and April 27, 2021.
You asked the Plan to pay for the gingival irrigations and scalings and planings. You say that you did not get to choose who would see you and you would like these services to be covered. The Plan denied your request. The Plan says the gingival irrigation is not a covered benefit under your dental plan. The Plan also says that you are responsible for a 50% coinsurance for the scalings and planings.
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, gingival irrigation (D4921) is not among those covered under this benefit. The contract says that periodontal scaling and root planing (D4341) is a covered service, and you are responsible for a 50% coinsurance. Therefore, we decided that the Plan does not have to pay for the gingival irrigations (D4921) and periodontal scalings and root planings (D4341) provided on April 26, 2021, and April 27, 2021.
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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically necessary.
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 do 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 documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve services of home health/hospice aide in home health or hospice settings, each 15 minutes, (G0156).
You asked the Plan to pre-approve the home health aide services. You say that you need assistance showering. You say that you have fallen many times. You say that you do not want that to happen anymore as you are afraid of injuring yourself. The Plan denied your request. The Plan says all home health requests must be certified by a doctor that they are necessary. The Plan also says that there is no order from your doctor for the requested service.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. We looked at file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the home health aide services have not been met. Specifically, there is no order from your doctor for the service. Therefore, we decided that the Plan does not have to pre-approve services of home health/hospice aide in home health or hospice settings, each 15 minutes, (G0156).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2740) for tooth #21.
You asked the Plan to pre-approve the crown for tooth #21. You say that you went to get a crown on tooth #21. You say that this should be covered. You say that all of the other crowns were covered. You also say that you do not understand why this crown would not be covered too. The Plan denied your request. The Plan says 2 crowns are covered per year. The Plan also says that the frequency limit has been reached.
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 crowns are listed as covered, the frequency limit has been reached. The record shows that the Plan has approved the crowns for teeth #12 and 14, thus reaching the benefit limit. Therefore, we decided that the Plan does not have to pre-approve a crown (D2740) for tooth #21.