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

 We decided that the Plan does not have to pre-approve an interspinous spacer placement (22870).  You asked the Plan to pre-approve the interspinous spacer placement. You say that the procedure is medically necessary. The Plan denied your request. The Plan says this procedure is experimental and non-covered.  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 interspinous spacer placement. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found interspinous devices are considered experimental. More research is needed to show safety and efficacy.  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 interspinous spacer placement have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous spacer placement (22870).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the glider (E0637).

You asked the Plan to pre-approve the glider. You say that you would like reconsideration because this equipment is medically necessary. The Plan denied your request. The Plan says the glider does not serve a primarily 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. Additionally, per Medicare, this specific CPT code is excluded from coverage. Therefore, we decided that the Plan does not have to pre-approve the glider (E0637).
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve facet joint injections.  You asked the Plan to pre-approve facet joint injections. You say that you are in extreme pain and need assistance. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because you had anterior lumbar interbody fusion at level L4-L5 which is a coverage exclusion.  The Plan follows Medicare rules. Medicare rules state that facet joint interventions may be covered under certain circumstances but are considered not reasonable and necessary after anterior lumbar interbody fusion.  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 facet joint injections. Our reviewer says that you do not meet the Medicare criteria for the requested facet joint injections. Our physician reviewer found you had surgery at the level of the planned facet joint injections, which is a Medicare coverage exclusion.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint injections.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.  You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied your request. The Plan says you do not meet Medicare criteria for coverage of SNF care.  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 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the case file does not contain documentation of stage II/IV pressure ulcers, a widespread skin disorder, or complex wounds requiring nursing wound treatment. You may be expected to benefit from skilled therapy, but services can be safely provided at a lower level of care.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for a monovisc injection provided on September 20, 2021. We also decided that the Plan does not have to waive the copayment for a specialist visit provided on September 20, 2021.  You asked the Plan to waive the coinsurance for the injection and specialist visit. You say that you cannot afford these charges. The Plan denied your request. The Plan says the correct coinsurance and copayment were 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). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Part B drugs, including injectable pain relief drugs.  Your contract with the Plan also clearly says that you must pay a $5 copayment for each specialist visit.   You have been asked to pay $316.23, which is 20% of the allowed amount for the injection ($1581.17 allowed amount x 20% coinsurance = $316.23). The injection falls within the Medicare Part B Prescription Drugs benefit category. You have also been asked to pay a $5 copayment for the specialist visit. The specialist visit falls within the Physician/Practitioner Services, Including Doctor's Office Visits benefit category. The total for the visit is $321.23. 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 a monovisc injection provided on September 20, 2021. We also decided that the Plan does not have to waive the copayment for a specialist visit provided on September 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ophthalmological services (CPT code 92012) provided to the enrollee on September 21, 2021, by out-of-network providers.  You asked the Plan to pay for the out-of-network services. You say that the claim should be paid. The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider, and the services were not urgent or emergent, nor were they approved in advance.  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 the ophthalmological services (CPT code 92012) provided to the enrollee on September 21, 2021, by out-of-network providers.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve bone replacement grafts (D4263) and guided tissue regeneration services (D4266).  You asked the Plan to pre-approve the dental services. You say that these services are medically 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 bone replacement grafts (D4263) and guided tissue regeneration services (D4266).
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.  You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied your request. The Plan says you do not meet Medicare criteria for coverage of SNF care.  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 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not require skilled nursing services. You can receive skilled therapy services safely, at a lower level of care.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the power mobility device.  You asked the Plan to pre-approve the power mobility device.. You say that you would like reconsideration because you need this power mobility device to access the community. The Plan denied your request. The Plan says Medicare does not cover durable medical equipment to be used outside the home.  The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home.   The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve the power mobility device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the endodontic therapy, premolar tooth (excluding final restoration) (D3320), consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician (D9310) and intraoral - periapical first radiographic image (D0220) provided June 21, 2021, by a dental specialist.
You asked the Plan to pay for the root canal, dental consultation and intraoral x-ray. You say that you were not informed the costs of the services during your visit. The Plan denied your request. The Plan says the cost-sharing was applied correctly.
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 the root canal, dental consultation and intraoral x-ray with 80% coinsurance when provided by a dental specialist through the
Plan's specialty referral process. We looked at the file and Medicare rules. In this case the total usual and customary amount charged by the dentist for the services was $1,452. You have been asked to pay a total of $1,132. This means you have been asked to pay less than or equal to the correct amount of 80% coinsurance based on your contract with the Plan. Therefore, we decided that the Plan does not have to pay for the endodontic therapy, premolar tooth (excluding final restoration) (D3320), consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician (D9310) and intraoral - periapical first radiographic image (D0220) provided June 21, 2021, by a dental specialist.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the CT scan, thoracic spine; without contrast material (CPT code 72128-26) provided to the enrollee on April 22, 2021.
You asked the Plan to pay for the CT scan. You say that the claim should be paid. The Plan denied your request. The Plan says the service 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. Review of the medical records only support one (1) CT scan thoracic spine; without contrast material (72128-26) performed on April 22, 2021. Therefore, the second thoracic spine CT scan that was billed is not covered because there are no records provided that verify a second thoracic spine CT scan was performed. 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 pay for the CT scan, thoracic spine; without contrast material (CPT code
72128-26) provided to the enrollee on April 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the transit option from Numotion (CPT code K0108)
and attendant control, proportional, including all related electronics and fixed mounting hardware (CPT code
E2331).
You asked the Plan to pre-approve the items. You say that the items are necessary. The Plan denied your
request. The Plan says the items are 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 rules say that if an attendant control (E2331) is provided in addition to a beneficiary-operated drive control
system, it will be denied as non-covered. Furthermore, transit option from Numotion (K0108) is not covered
because it does not serve a medical need. Therefore, we decided that the Plan does not have to pre-approve the
transit option from Numotion (CPT code K0108) and attendant control, proportional, including all related
electronics and fixed mounting hardware (CPT code E2331).
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Dexlansoprazole.  You asked the Plan to pre-approve Dexlansoprazole. The Plan denied your request. The Plan says Dexlansoprazole is a self-administered drug. The Plan also says that this medication does not fall under Part B coverage.  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 Dexlansoprazole.   Benefits for Dexlansoprazole 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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a surgical placement of implant body: endosteal implant (D6010).  You asked the Plan to pre-approve an endosteal implant. You say that you need this implant to replace a tooth. The Plan denied your request. The Plan says this service is not covered under your 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 pre-approve a surgical placement of implant body: endosteal implant (D6010).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210), removal of residual tooth roots (cutting procedure) (D7250), immediate maxillary partial denture - resin base (including retentive/clasping materials, rests and teeth) (D5221), and immediate mandibular partial denture - resin base (including retentive/clasping materials, rests and teeth) (D5222) provided October 12, 2021.  You asked the Plan to pay for the tooth extraction, removal of residual tooth roots, immediate upper partial denture and immediate lower partial denture. You say that you were in pain and would like the services covered. The Plan denied your request. The Plan says the services are not covered because they were provided out-of-network.  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 the tooth extraction, removal of residual tooth roots, immediate upper partial denture and immediate lower partial denture when the services are obtained from a provider in the Plan's dental vendor network.   We looked at the file and Medicare rules. 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. Based on this information, we decided that the Plan's rules for coverage of the tooth extraction, removal of residual tooth roots, immediate upper partial denture and immediate lower partial denture have not been met. Therefore, we decided that the Plan does not have to pay for extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210), removal of residual tooth roots (cutting procedure) (D7250), immediate maxillary partial denture - resin base (including retentive/clasping materials, rests and teeth) (D5221), and immediate mandibular partial denture - resin base (including retentive/clasping materials, rests and teeth) (D5222) provided October 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) provided September 15, 2021.  You asked the Plan to pay for the limited oral exam. You say that you would like this service covered. The Plan denied your request. The Plan says you have exceeded the frequency limit for this service.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the limited oral exam once per plan year.   We looked at the file and Medicare rules. The Plan provided documentation showing that a limited oral exam was previously covered on August 26, 2021. Based on this information, we decided that the Plan's frequency limit for coverage of the limited oral exam has been exceeded. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) provided September 15, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care.  You asked the Plan to pre-approve continued SNF care. You say that the requested continuation of SNF care is medically necessary. The Plan denied your request. The Plan says the requested services are not medically necessary.  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 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 continued SNF care. Our reviewer says that you do not meet the Medicare criteria for SNF care. Our physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued SNF care have not been met. Specifically, the file does not show that you require daily skilled services. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for an adjacent tissue transfer or rearrangement (14001) provided April 12, 2021.  You asked the Plan to pay for an adjacent tissue transfer. You say that you would like reconsideration based on the medical records provided. The Plan denied your request. The Plan says the billed code is not supported 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.  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 an adjacent tissue transfer. Our reviewer says that the billed code is not supported for payment. Our reviewer found the operative report does not include enough detail to confirm the type of closure after the breast has been removed. Closures are included with the primary procedure if a cutaneous closure. If a more complex closure including pedicle, then this procedure should 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 an adjacent tissue transfer have not been met. Therefore, we decided that the Plan does not have to pay for an adjacent tissue transfer or rearrangement (14001) provided April 12, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory service (88305) rendered by the out-of-network (OON) provider on October 7, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.
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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service 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 this service. Therefore, we decided that the Plan does not have to pay for the laboratory service (88305) rendered by the out-of-network (OON) provider on October 7, 2021.