Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve addition, endoskeleton system, below knee, alignable system (L5910).  You asked the Plan to pre-approve alignable below knee system addition. You say that the enrollee needs this item. The Plan denied your request. The Plan says the enrollee has been approved for a non-alignable prosthesis, and therefore, an alignable addition is not medically necessary.  The Plan must follow Medicare rules. Medicare rules say that when an initial below knee prosthesis (L5500) or a preparatory below knee prosthesis (L5510, L5520, L5530, L5540) is provided, prosthetic substitutions and/or additions of procedures and components are covered in accordance with the functional level assessment.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of alignable below knee system addition have not been met. Specifically, an alignable addition will not work with a non-alignable system. This means the requested item is not medically necessary. Therefore, we decided that the Plan does not have to pre-approve addition, endoskeleton system, below knee, alignable system (L5910).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Life2000 system.  You asked the Plan to pre-approve a Life2000 system. You say that the requested device is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been met.  The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD.  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 Life2000 system. Our reviewer says that the requested item is not medically reasonable and necessary. Our physician reviewer found the Life2000 system is not medically necessary. This system is not a true ventilator.  It is a portable positive pressure device delivered via a nasal pillows interface, meant to be used during activity. There is insufficient evidence of efficacy in the treatment of COPD. In addition, coverage criteria for a home ventilator are not met. There is no documentation of CO2 retention, and nocturnal BiPAP has not been tried. The denial of the Life2000 system is upheld.  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 Life2000 system have not been met. Therefore, we decided that the Plan does not have to pre-approve a Life2000 system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), bitewings (D0274), and a resin-based composite (D2393) provided by June 3, 2021, to July 1, 2021.  You asked the Plan to pay for a periodic oral evaluation, bitewings, and a resin-based composite. You say that you were told that this would be billed as usual. The Plan denied your request. The Plan says services must be provided by an in-network provider.  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 a periodic oral evaluation, bitewings, and a resin-based composite when the services are provided by an in-network provider.    We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a periodic oral evaluation, bitewings, and a resin-based composite have not been met. Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation (D0120), bitewings (D0274), and a resin-based composite (D2393) provided by June 3, 2021, to July 1, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the lumbar spine.  You asked the Plan to pre-approve CT scan services. You say that the requested service is medically reasonable and necessary. The Plan denied your request. The Plan says the criteria for coverage have 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 CT scan services. Our reviewer says that the requested imaging service is not medically reasonable and necessary. Our physician reviewer found that the record indicates that the enrollee has had a previous lumbar fusion in 2017 and was struck by a motor vehicle in 2018. The enrollee has undergone a magnetic resonance imaging (MRI) scan in September 2021. The provided records do not indicate the medical necessity or reasonableness, as defined by Medicare rules, of the requested service at this time. The elements of the coverage criteria 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 CT scan services have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the lumbar spine.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for the psychotherapy visits provided from July 9, 2021, to August 25, 2021.  You asked the Plan to waive the copayments for the psychotherapy visits. You say that your visits were coronavirus-related, and you were never told that your telehealth visits ended in June 2021. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.    The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for each individual/group therapy visit.   You have been asked to pay a $40 copayment for each of the psychotherapy visits. The psychotherapy visits fall within the "Outpatient mental health care" benefit category. The record shows you were notified via e-mail that the copayment waiver ended on June 30, 2021. 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 copayments for the psychotherapy visits provided from July 9, 2021, to August 25, 2021.
Appeal type: Practitioner Services
Decision: Partially Favorable

 We decided that the Plan has to waive the copayments for the ultrasounds. We decided that the Plan does not have to reduce the copayments for the physical therapy visits.   You asked the Plan to reduce the copayments for the physical therapy visits and the ultrasounds. You say that you are being overcharged for the visits. The Plan says that you have been asked to pay the correct cost-sharing amount.  We decided that the Plan has to waive the copayments for the ultrasounds.   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 does not say in clear and accurate terms how much you should expect to pay for wound care when provided by a physical therapist.   We looked at your contract with the Plan. We did not see where the contract says enrollees must pay a $25 copayment or a $35 copayment for wound care when provided by a physical therapist. The Plan contract does not clearly say how much enrollees must pay for wound care when provided by a physical therapist. This means that the Plan did not follow Medicare rules for disclosure of cost sharing information. The record shows the ultrasounds (97610) are considered active wound care management and a professional service. Therefore, we decided that the Plan has to waive the copayments for the ultrasounds provided from February 5, 2021, to March 8, 2021.    We also decided that the Plan does not have to reduce the copayments for the physical therapy visits.  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 the physical therapy visits. Therefore, we decided that the Plan does not have to reduce the copayments for the physical therapy visits.  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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the vanity flap and back post (K0108).  You asked the Plan to pre-approve the vanity flap and back post. You say that the enrollee needs these items. The Plan denied your request. The Plan says these items do not primarily serve a medical purpose.    The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.    The item at issue in this appeal does not serve a purpose that is primarily medical in nature. 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 the vanity flap and back post (K0108).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for physical therapy services provided from April 28, 2021, to May 21, 2021.  You asked the Plan to waive the copayments for physical therapy. You say that you are requesting reimbursement for the fees you paid. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for each physical therapy visit.   You have been asked to pay a $40 copayment for each physical therapy visit. You had eight visits for a total of $320 (8 visits x $40 copayment each = $320). Physical therapy falls within the Outpatient Rehabilitation 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 copayments for physical therapy services provided from April 28, 2021, to May 21, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from June 6, 2021, to June 14, 2021.  You asked the Plan to pay for the SNF care provided from June 6, 2021, to June 14, 2021. You say that the services are coverable under the Medicare Act. The Plan denied your request. The Plan says that the enrollee did not receive skilled care on the dates of service in this case.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.  We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF care provided from June 6, 2021, to June 14, 2021, have not been met. Specifically, the file does not show that the enrollee received skilled services on the dates of service in this case. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from June 6, 2021, to June 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the periodontal scaling and root planing (D4341 x 2) provided on June 8, 2021.  You asked the Plan to pay for the dental services. You say that you did not receive these services. You say that the dentist only did polishing and did not clean the tartar from the bottom of your teeth. You say that you did not receive an oral evaluation either. The Plan denied your request. The Plan says periodontal scaling and root planing are not covered services.  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 scaling and root planing are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the periodontal scaling and root planing (D4341 x 2) provided on June 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve A heavy duty extra wide hospital bed (E0303).  You asked the Plan to pre-approve A heavy duty extra wide hospital bed. You say that the enrollee needs this item. The Plan denied your request. The Plan says the enrollee does not meet the criteria for the requested item and is currently using a similar item.  The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary.  The file shows that you have semi-electric bed with a gel pressure mattress. semi-electric bed with a gel pressure mattress serves the same purpose as A heavy duty extra wide hospital bed. Therefore, we decided that the Plan does not have to pre-approve A heavy duty extra wide hospital bed (E0303).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the resin-based composite - two surfaces, posterior (D2392) and resin-based composite - one surface, anterior (D2330) provided July 9, 2021.  You asked the Plan to pay for the resin-based composites. You say that you didn't know you could have signed up for additional benefits and feel that treatment for cavities should be covered. The Plan denied your request. The Plan says you have exceeded your dental benefit maximum.  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 resin-based composites up to the $500 annual maximum.   We looked at the file and Medicare rules. In this case the Plan provided documentation showing that you used your full $500 annual benefit prior to receiving the services at issue. Therefore, we decided that the Plan does not have to pay for the resin-based composite - two surfaces, posterior (D2392) and resin-based composite - one surface, anterior (D2330) provided July 9, 2021.   Your complaint about which services are covered under your plan and potentially not being provided complete information about your dental options is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the home health aide services (S9122), up to 35 hours per week, provided from June 1, 2021, to June 13, 2021.  You asked the Plan to pay for the home health aide services. You say that you were not made aware that the services being billed would not be considered as part of the home health services. You also say that the services provided were necessary as you were not able to change your bag on your own. The Plan denied your request. The Plan says the personal care you received is considered custodial in nature. The Plan says that custodial care is not covered by Medicare or the Plan.  The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from trained medical or paramedical staff, is not covered.   We looked at the 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, we find that the services at issue in this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pay for the home health aide services (S9122), up to 35 hours per week, provided from June 1, 2021, to June 13, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve 24 additional physical therapy visits.  You asked the Plan to pre-approve 24 additional physical therapy visits. You say that the services are medically necessary. The Plan denied your request. The Plan says the services 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-approve 24 additional physical therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found based on the available records the enrollee appears to have improved with the therapy that has been provided thus far to the point of being better able to "lift and perform chores." With the additional twelve physical therapy visits approved by the Plan, further improvement in motion and function should be achieved. Records do not document why the previously approved treatment plus the recently approved 12 additional treatments are inadequate to treat the enrollee's condition.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 24 additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 24 additional physical therapy visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on July 12, 2021.  You asked the Plan to pay for the dental service. You say that this should be covered in full. The Plan denied your request. The Plan says 1 limited oral evaluation is covered per plan year. The Plan also says that 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.  We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental service have not been met. Specifically, the frequency limit has been exceeded. The record shows that the Plan paid for a limited oral evaluation that you received on April 6, 2021. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on July 12, 2021.
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 this item. The Plan denied your request. The Plan says this is not a covered item.  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 pay for the 2D photographic images (D0350 x 4), oral hygiene instructions (D1330), and unspecified periodontal service (D4999) provided on June 23, 2021.  You asked the Plan to pay for the 2D photographic images, oral hygiene instructions and unspecified periodontal service. You say that the dental office called the plan before rendering the services and advised they would be covered. You also say that you should not be responsible for this bill. The Plan denied your request. The Plan says the services you received are not listed as covered. The Plan also says that there is no record of any calls to customer service prior to the date of service regarding the plan benefits or authorization.  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 2D photographic images, oral hygiene instructions and unspecified periodontal service are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 2D photographic images (D0350 x 4), oral hygiene instructions (D1330), and unspecified periodontal service (D4999) provided on June 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services (63707) provided on May 26, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not supported.  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 asked our coder 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 services. Our reviewer says that the use of code 63707 is not supported by the records provided. Our reviewer found that per Medicare, "If a dural (cerebrospinal fluid) leak occurs during a spinal procedure, repair of the dural leak is integral to the spinal procedure. CPT code 63707 or 63709 (Repair of dural/cerebrospinal fluid leak) shall not be reported separately for the repair".  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 services have not been met. Therefore, we decided that the Plan does not have to pay for the services (63707) provided on May 26, 2021.