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

We decided that the Plan does not have to pre-approve a removal of torus palatinus (D7472).

You asked the Plan to pre-approve a removal of torus palatinus. You say that this bone is getting in the way of
your regular dental care and removing it is necessary. The Plan denied your request. The Plan says this service
is not covered by your dental 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
removal of torus palatinus (D7472).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the 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 LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the case file does not indicate that the enrollee requires acute care services that they are not currently receiving but that would be available at the LTACH facility. The elements of the coverage rule are not satisfied. The requested service cannot be recommended. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve laparoscopy, surgical; repair initial inguinal hernia (CPT code 49650) to be performed by an out-of-network provider.
You asked the Plan to pre-approve the services. You say that the service is medically necessary. The Plan denied your request. The Plan says this provider is not in-network. The Plan states there is an in-network provider who can evaluate and treat you.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve laparoscopy, surgical; repair initial inguinal hernia (CPT code 49650) to be performed by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Medicare Part B covered drug.
You asked the Plan to waive the coinsurance for the Medicare Part B covered drug. You say that your provider
and billing department made no mention of having out-of-pocket costs. The Plan denied your request. The Plan
says you have been charged the coinsurance 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 20%
coinsurance for Medicare Part B prescription drugs.
You have been asked to pay 20% coinsurance for the coinsurance for the Medicare Part B covered drug. The
coinsurance for the Medicare Part B covered drug falls within the Medicare Part B prescription drugs 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 Medicare Part B covered drug.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal scaling and root planing of four or more teeth per quadrant (D4341) for all four quadrants.
You asked the Plan to pre-approve periodontal scaling and root planing. You say that these services are necessary, and you have already lost one tooth due to substance build up. The Plan denied your request. The Plan says these services are not necessary. Documentation does not show evidence of significant bone loss. There is some radiographic evidence of calculus, but this is not on the root surface. Criteria are not met.
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 periodontal scaling and root planing when the services are medically necessary and reasonable. D4341 may be found medically necessary and reasonable when there is periodontal disease noted on four or more teeth in a quadrant, and these teeth show notable bone loss from the disease process. 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 periodontal scaling and root planing. Our reviewer says that these services are not necessary and do not meet criteria.
Our physician reviewer found that in this instance there is no notable bone loss seen, and any tartar seen is on enamel surfaces as the root surfaces are not accessible below the level of the attachment. Since there is no notable bone loss seen on the provided x-rays, there can be no finding of medical necessity for four quadrants of scaling and root planing. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of periodontal scaling and root planing have not been met. Therefore, we decided that the Plan does not have to pre-approve periodontal scaling and root planing of four or more teeth per quadrant (D4341) for all four quadrants.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says there appears to be some concerns that the device is not as effective as surgical decompression, and may lead to higher rates of re-operation.

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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device is experimental. More research is needed to show safety and efficacy of the device. 

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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
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 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. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. You do 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 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 pre-approve a shroud assembly for a power wheelchair.

You asked the Plan to pre-approve the item. You say that this is medically necessary. The Plan denied your request. The Plan says this item is for use when the wheelchair is outside of the home.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose and be needed for use inside the home.

The item at issue in this appeal does not serve a purpose that is primarily medical in nature, and is meant for outdoor use. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a shroud assembly for a power wheelchair.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex Superion spacer device.
You asked the Plan to pre-approve the device. The Plan denied your request. The Plan says this is 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 the device. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found that the Vertiflex device is experimental. More research is needed to show safety and efficacy of the
device.
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 device have not been met. Therefore, we decided that the Plan does not have
to pre-approve Vertiflex Superion spacer device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the 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 LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the case file does not indicate that the enrollee requires acute care services that he is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rule are not satisfied. The requested service cannot be recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional 35 transportation trips
You asked the Plan to pre-approve an additional 35 transportation trips. You say that you would like the Plan to pre-approve more trips so you can get to appointments. The Plan denied your request. The Plan says you have utilized the maximum number of transportation trips allowed per year.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 52 one-way trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve an additional 35 transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bone replacement graft (D4263) and guided tissue regeneration (D4266).

You asked the Plan to pre-approve the dental services. You say that these services are necessary. The Plan denied your request. The Plan says these services are not covered by your dental 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 bone replacement graft (D4263) and guided tissue regeneration (D4266).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the over-the-counter drug allowance of $25 from the
first quarter added to the second quarter.

You asked the Plan to pre-approve the over-the-counter drug allowance of $25 from the first quarter added to
the second quarter. The Plan denied your request. The Plan says quarterly allowances cannot be carried over to
another quarter.

The Plan contract says that quarterly allowances cannot be carried over to another quarter.

We looked at the file and the Plan's rules. The file shows that that quarterly allowances cannot be carried over
to another quarter. Therefore, we decided that the Plan does not have to pre-approve the over-the-counter
benefit allowance of $25 from the first quarter added to the second quarter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four testing (CPT 95999) provided to the enrollee on
August 24, 2020.

You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request.
The Plan says the cost of this is included in the primary procedure.

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, the CPT Code Manual definition of code 95999 is "unlisted neurological or neuromuscular
diagnostic procedure."

We asked our coding 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. Our reviewer says that the
services at issue in this case were not supported by the medical records. Our coding reviewer found Train of
Four Monitoring does not fit the criteria set by CMS for CPT 95999. CPT 95999 is bundled into primary
service. There is no separate code for this service. Therefore, it should not be reported separately.

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for train of four testing (CPT 95999) provided to the enrollee on August 24, 2020.
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 want to avoid falls and complications with your legs. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve three porcelain/ceramic crowns (D2740).

You asked the Plan to pre-approve the crowns. You say that these crowns are necessary The Plan denied your request. The Plan says this type of crown is not covered by your dental 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 three porcelain/ceramic crowns (D2740).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (D3331).
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says code D3331 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
dental services (D3331).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for an over-the-counter benefit allowance of $25 from the first quarter added to the second quarter.
You asked the Plan to reimburse you for an over-the-counter benefit allowance of $25 from the first quarter added to the second quarter. The Plan denied your request. The Plan says quarterly allowances cannot be carried over to another quarter.
The Plan contract says that quarterly allowances cannot be carried over to another quarter.
We looked at the file and the Plan's rules. The file shows that that quarterly allowances cannot be carried over to another quarter. Therefore, we decided that the Plan does not have to reimburse you for an over-the-counter benefit allowance of $25 from the first quarter added to the second quarter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve removal of an impacted tooth (D7240) for tooth #32.

You asked the Plan to pre-approve the tooth extraction. You say that removal of this tooth is necessary in order for the enrollee to continue using their dentures. The Plan denied your request. The Plan says this service is not covered by the Plan's dental 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 removal of an impacted tooth (D7240) for tooth #32.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided on October 25, 2020.

You asked the Plan to pay for acute inpatient hospital care. You say that the requested care was a medical necessity for the enrollee. The Plan denied your request. The Plan says that rules for inpatient admission have not been met.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 

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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found that the enrollee presented to the emergency department (ED) on October 25, 2020, with uncontrolled diabetes and left foot pain. He was evaluated and was noted to have a left foot wound that was draining purulent material. The record shows that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span two midnights. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided on October 25, 2020.

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.