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

 We decided that the Plan does not have to pre-approve a multiple braking system heavy duty walker (E0147).  You asked the Plan to pre-approve a multiple braking system heavy duty walker. You say that this item is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been satisfied.  The Plan follows Medicare rules. Medicare rules say that a heavy duty, multiple braking system, variable wheel resistance walker (E0147) is covered for beneficiaries who meet coverage criteria for a standard walker and who are unable to use a standard walker due to a severe neurologic disorder or other condition causing the restricted use of one hand.  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 multiple braking system heavy duty walker. Our reviewer says that the requested multiple braking system heavy duty walker is not medically reasonable and necessary. Our physician reviewer found based on the medical records provided there is no documentation that the enrollee satisfies the coverage criteria for the requested heavy duty walker with multiple braking system. Records do not clearly document that coverage criteria for a standard walker are met and that the enrollee is unable to use a standard walker due to a severe neurologic disorder or other condition causing the restricted use of one hand.  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 multiple braking system heavy duty walker have not been met. Therefore, we decided that the Plan does not have to pre-approve a multiple braking system heavy duty walker (E0147).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the retreatment of a previous root canal (D3347) provided on September 21, 2021.  You asked the Plan to pay for the dental service. You say that you are on a low income. You say that you were advised you had to pay $306. You say that you did not know that your insurance would not cover the rest. You also say that you need help. The Plan denied your request. The Plan says 1 root canal procedure is covered per calendar 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.  Though the Plan offers a dental benefit in excess of Medicare coverage, the frequency limit has been exceeded. The record shows that the Plan paid for retreatment of a previous root canal that you received on August 17, 2021. Therefore, we decided that the Plan does not have to pay for the retreatment of a previous root canal (D3347) provided on September 21, 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 does not meet criteria.  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 you do not require the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Care at the skilled nursing facility level appears to be appropriate in this case.  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: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a referral to an out-of-network provider for magnetic resonance imaging (MRI).  You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are available from network providers.  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 a referral to an out-of-network provider for magnetic resonance imaging (MRI).
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an epidural steroid injection.  You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says no further interventional therapy is indicated at this point.  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 procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has not had a recent physical exam and inadequate trials of conservative therapy. Therefore, the request is considered not medically reasonable or necessary.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve an epidural steroid injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and accessory (E0667).  You asked the Plan to pre-approve a pneumatic compression device and accessory. You say that a basic pump would be ineffective and unsafe for the enrollee. The Plan denied your request. The Plan says the requirements for coverage have not been met.  The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.  We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and accessory (E0667).
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the radiofrequency ablation (64625) provided on September 9, 2021.  You asked the Plan to pay for the radiofrequency ablation (64625). You say that the medical records support the services provided and the claim should be reprocessed. The Plan denied your request. The Plan says radiofrequency ablation used for sacroiliac joint pain is considered not medically necessary/investigational.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.     We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the radiofrequency ablation (64625). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is considered an experimental/ investigational procedure because of the wide variation in efficacy described in the literature.  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 radiofrequency ablation (64625) have not been met. Therefore, we decided that the Plan does not have to pay for the radiofrequency ablation (64625) provided on September 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a left foot accelerator driving device.  You asked the Plan to pre-approve these services. You say that the enrollee's foot drop affects his gait and ability to drive. The Plan denied your request. The Plan says the item is not covered.  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 a left foot accelerator driving device.
Appeal type: Drugs
Decision: Unfavorable

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

 We decided that the Plan does not have to pre-approve LTACH services.  You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically necessary.  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 based on the documentation provided you only require short-term additional acute care services that can safely be administered at the current facility. You do not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that you require that are not already available and covered at the current facility.    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 LTACH services.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for radiology services (71260) provided September 26, 2021.  You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The Plan denied your request. The Plan says the code billed shares a bundled relationship with another code billed and is not separately payable.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 71260 is a column II code to column I code 71275. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for radiology services (71260) provided September 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a mandibular partial denture (D5214).  You asked the Plan to pre-approve the mandibular partial denture. You say that you would have liked to have had this procedure completed by December but then the prior authorization had been denied. The Plan denied your request. The Plan says this service exceeds the maximum count allowed per period.  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, mandibular partial denture (D5214) is limited to one procedure every five plan years. The record shows that you received a mandibular partial denture (D5214) on August 3, 2021 and your mandibular partial denture (D5214) benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve a mandibular partial denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to reimburse you for oral exam (D0120), cleaning (D1110), bitewing x-rays (D0274), and filling (D2392) provided from July 8, 2021, to July 29, 2021.  You asked the Plan to reimburse you for the dental services. You say that your coverage says $1,000 annual allowance to use toward dental services. You say that it does not mention that certain dental offices are excluded. You also say that you are requesting reimbursement of $455. The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan also says that payment cannot be made to providers that have opted out of Medicare.  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 provided by a dentist that has opted out of Medicare are not among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for oral exam (D0120), cleaning (D1110), bitewing x-rays (D0274), and filling (D2392) provided from July 8, 2021, to July 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for digital breast tomosynthesis (77062) provided September 9, 2021.  You asked the Plan to pay for the diagnostic service. You say that you had the same service done a year ago and the Plan covered it. Your in-network doctor requested these two tests but you have been told this time, they would not pay for one of the screening tests that you needed. The Plan denied your request. The Plan says the additional breast cancer screening imaging is not valid for payment  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 77062 is digital breast tomosynthesis.  We find that CPT code 77062 is not supported in the medical record. Specifically,77062 has a status indicator of "I" which indicates the code is not valid for Medicare. There is a more appropriate code that the provider should have billed. Based on this information, we decided that Medicare rules for coverage of the diagnostic service have not been met. Therefore, we decided that the Plan does not have to pay for digital breast tomosynthesis (77062) provided September 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for INR monitoring equipment provided on September 7, 2021.  You asked the Plan to waive the coinsurance for the monitoring equipment. You say that you were informed that the machine was no charge. The Plan denied your request. The Plan says the correct coinsurance was applied.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a 20% coinsurance for durable medical equipment (DME), including INR monitors.     The enrollee has been asked to pay $15.71, which is 20% of the allowed amount for the monitoring equipment ($78.53 allowed amount x 20% coinsurance = $15.71). The monitoring equipment falls within the Durable Medical Equipment (DME) and Related Supplies benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for INR monitoring equipment provided on September 7, 2021.
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 requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.  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 enrollee appears to be improving gradually, however, only additional short-term acute care services are needed that can be safely received at the current facility until completed. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer to a lower level of care may be considered when treatment has completed.    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: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for X-rays of the chest provided on September 15, 2021.  You asked the Plan to waive the copayment for the X-rays. You say that you feel the copayment should be waived since your PCP did not have X-ray equipment in the office. 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 $90 copayment for basic radiological services provided at an outpatient hospital, including X-rays.   You have been asked to pay $72.66, which is less than the $90 copayment for the X-rays. The X-rays fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 X-rays of the chest provided on September 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for labs services (83789, G0480, 80307) provided on August 4, 2021.  You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the out-of-network services were not pre-authorized or emergent.  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 services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for labs services (83789, G0480, 80307) provided on August 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for lead wires (A4557) provided September 28, 2021.  You asked the Plan to pay for the lead wires. You say that the items were medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.  The Plan must follow Medicare rules. Medicare rules say that replacement of lead wires more often than every 12 months would rarely be reasonable and necessary.  We looked at the file and Medicare rules. The provided records do not describe why replacement lead wires were medically necessary. Based on this information, we decided that Medicare rules for coverage of the lead wires have not been met. Therefore, we decided that the Plan does not have to pay for lead wires (A4557) provided September 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the presbyopia correcting function of intraocular lens (P-C IOL) (V2788) provided May 6, 2021, and May 27, 2021.  You asked the Plan to pay for the P-C IOL. You say that these lenses are medically necessary due to your nerve condition. The Plan denied your request. The Plan says this feature is not covered under Medicare or your plan.  The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives a P-C IOL during cataract surgery, the enrollee will be responsible for the difference in cost between the P-C IOL and a conventional IOL.   While a P-C IOL may be appropriate for you, neither the Plan nor Medicare covers the presbyopia-correcting feature of a P-C IOL. Therefore, we decided that the Plan does not have to pay for the presbyopia correcting function of intraocular lens (P-C IOL) (V2788) provided May 6, 2021, and May 27, 2021.