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

We decided that the Plan does not have to provide additional payment for the complete denture - maxillary (D5110) and complete denture - mandibular (D5120) provided April 14, 2021.

You asked the Plan to provide additional payment for the complete upper and lower denture. You say that you would like the dentures covered. The Plan denied your request. The Plan says your full $1,000 annual maximum has been applied to your 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. The Plan covers the complete upper and lower denture once every five years up to a $1,000 annual maximum. 

We looked at the file and Medicare rules. The Plan provided documentation showing that the full $1,000 annual maximum has been applied to your claims. Based on this information, we decided that the Plan's dental maximum has been exhausted. Therefore, we decided that the Plan does not have to provide additional payment for the complete denture - maxillary (D5110) and complete denture - mandibular (D5120) provided April 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on January 18, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the lumbar-sacral orthosis. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
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. The records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on January 18, 2021, by an out-of-network (OON) provider
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from October 6, 2020,
through October 11, 2020.
You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says that
the inpatient admission was not reasonable and necessary.
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 6, 2020 with a left toe
and foot infection that had failed outpatient treatment. Her related medical conditions were diabetes, coronary
artery bypass grafting, heart failure, morbid obesity and wheelchair bound. On initial presentation she was
hypertensive but otherwise vitals were non-contributory. White count was 6.4. The x-ray did not show acute
infection, only mineral changes consistent with gout and soft tissue swelling. She was started on intravenous
antibiotics and admitted. Her condition stabilized and improved, and she was discharged home
October 11, 2020 when considered medically stable. The review has determined that the record showed that at
the time of inpatient admission the admitting physician reasonably expected that the patient'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 from October 6, 2020, through October 11, 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
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for Sanexas neoGen Series Therapy provided to the enrollee from August 27, 2020, to November 11, 2020.

You asked the Plan to pay for the therapy. You say that this should be paid for. The Plan denied your request. The Plan says experimental or investigational services are not 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 pay for the therapy. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the peer-reviewed medical literature has not demonstrated the efficacy or clinical utility of nerve blockade electrical stimulation alone or used together in the diagnosis and/or treatment of neuropathic pain.

The peer-reviewed medical literature has not demonstrated effectiveness of high frequency electrical nerve stimulation and peripheral nerve block, for all indications. 

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 therapy have not been met. Therefore, we decided that the Plan does not have to pay for Sanexas neoGen Series Therapy provided to the enrollee from August 27, 2020, to November 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for services provided between 10:00 PM and 8:00 AM (99053) on March 23, 2021.

You asked the Plan to pay for services provided between 10:00 PM and 8:00 AM. You say that this is supported in the records. The Plan denied your request. The Plan says this is not separately payable.

The Plan must follow Medicare rules. Medicare rules say that a Medicare Physician Fee Schedule Database (MPFSDB) Status Indicator of B indicates that payment for covered services is always bundled into payment for other services not specified. 

We looked at the file and Medicare rules. Code 99053 has a status indicator of B, meaning it is not separately payable. Based on this information, we decided that Medicare rules for coverage of services provided between 10:00 PM and 8:00 AM have not been met. Therefore, we decided that the Plan does not have to pay for services provided between 10:00 PM and 8:00 AM (99053) on March 23, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient services provided from May 31, 2021, through
June 3, 2021.
You asked the Plan to pay for inpatient services. The Plan denied your request. The Plan says that the medical
records demonstrate the enrollee's emergency medical condition was stabilized by 10:25 a.m. on June 2, 2021
to 2:30 p.m. on June 3, 2021, such that it met the Medicare standard for transferability namely that within
reasonable medical probability no material deterioration of her condition was likely to result from or occur
during transfer had the enrollee been transferred to a Plan facility on June 2, 2021.
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider,
approval is required.
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 inpatient services. Our reviewer says that
inpatient services at the non-contract hospital were not necessary. Our physician reviewer found that as of
10:25 a.m. on June 2, 2021 to 2:30 p.m. on June 3, 2021, the enrollee was hemodynamically stable and
appropriate for ambulance transport with monitoring to a Plan facility. There was no documentation provided
indicating medical necessity for post-stabilization care services at the non-Plan facility as of 10:26 a.m. on
June 2, 2021. The review indicates that the treating physician did not document (in the physician notes, on a
form, or in an order) that the enrollee was not stable for transfer on any dates of service.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of inpatient services have not been met. Therefore, we decided that the Plan does
not have to pay for inpatient services provided from May 31, 2021, through June 3, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve minimally-invasive right-sided percutaneous sacroiliac
fusion for the enrollee.
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied
your request. The Plan says the clinical value and effectiveness of a minimally invasive right-sided
percutaneous sacroiliac(SI) fusion in the setting of multifactorial low back pain and bilateral SI joint disease
have not been demonstrated in the peer-reviewed literature.
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 degenerative back pain. This request remains experimental in cases where there
is no sacroiliac joint instability.
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 minimally-invasive right-sided percutaneous sacroiliac fusion for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial lower denture (D5214).
You asked the Plan to pre-approve a partial lower denture. You say that the requested partial lower denture is
medically necessary. The Plan denied your request. The Plan says the requested partial lower denture is not
medically necessary. To qualify for a partial denture, you must have less than eight back teeth that touch. This
means that you have less than four upper back teeth that touch four of your lower back teeth when you bite
down. The teeth that touch can include either natural or fake teeth. The x-rays show that you have eight or
more teeth that touch.
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 partial
lower denture when the services are medically necessary and reasonable.
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 partial lower denture. Our reviewer
says that the service is not medically necessary. Our physician reviewer found that a review of the enrollee's
dental record and radiographs indicate that a maxillary removable partial denture has been approved for
coverage. It appears that there are sufficient natural mandibular posterior teeth to give the patient adequate
masticatory function.
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 a partial lower denture have not been met. Therefore, we decided that the Plan
does not have to pre-approve a partial lower denture (D5214)
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140), surgical extraction
(D7210), and bone replacement graft (D4263) provided on August 13, 2021.
You asked the Plan to pay for the limited oral evaluation and bone replacement graft. You say that you were
asked to pay $338 upfront. You say that you were never told that this dentist was out of network. You say that
you told them you only wanted services if they would be covered. You also say that your trust was violated.
The Plan denied your request. The Plan says the limited oral evaluation is not listed as a covered service. The
Plan says that bone replacement graft is not listed as a covered service either.
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 limited oral evaluation and bone
replacement graft are not among those covered under this benefit. Therefore, we decided that the Plan does not
have to pay for the limited oral evaluation (D0140), surgical extraction (D7210), and bone replacement graft
(D4263) provided on August 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Biventricular implantable cardioverter defibrillator (ICD).
You asked the Plan to pre-approve a Biventricular implantable cardioverter defibrillator (ICD). You say that the requested Biventricular ICD implant is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested Biventricular ICD implant.
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 a Biventricular implantable cardioverter defibrillator (ICD). Our reviewer says that the enrollee does not meet criteria for the requested Biventricular ICD implant. Our physician reviewer found the enrollee is with chronic atrial fibrillation, with episodes of rapid ventricular response which has been difficult to control medically. The enrollee also has a history of hypertension, hyperlipidemia, and GERD, as well as nosebleeds thought to pose a contraindication to chronic anti-coagulation. The documentation does not support that the enrollee has a covered indication for an implantable automatic defibrillator as established by NCD 20.4. 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 Biventricular implantable cardioverter defibrillator (ICD) have not been met. Therefore, we decided that the Plan does not have to pre-approve a Biventricular implantable cardioverter defibrillator (ICD).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the porcelain crown (D2740) provided on January 7, 2021.
You asked the Plan to pay for the dental service. You say that you did not receive the Annual Notice of
Changes (AOC). You say that you were not able to find information regarding the 2021 benefit on the plan's
website. You also say that you were not aware that crowns were not offered in 2021. The Plan denied your
request. The Plan says porcelain crown is not listed as a covered service. The Plan also says that services that
you receive in 2021 must be considered in accordance with the 2021 plan benefit and not the plan benefit for
the previous year.
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 porcelain crown is not among those
covered under this benefit. Additionally, the record does not show that you called the Plan before you received
the service to verify your dental benefits. Therefore, we decided that the Plan does not have to pay for the
porcelain crown (D2740) provided on January 7, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the laboratory work provided on March 17, 2021.
You asked the Plan to pay for the laboratory work. You say that the service was medically necessary. The Plan denied your request. The Plan says that no prior authorization was obtained.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not show if the referring provider was an in-network or out-of-network physician. This means we are unable to confirm if they Plan correctly denied payment. Therefore, we decided that the Plan has to pay for the laboratory work provided on March 17, 2021.
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: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for eyeglasses provided on July 2, 2021.
You asked the Plan to pay for eyeglasses. You say that these are the first pair of eyeglasses after cataract surgery. The Plan denied your request. The Plan says that the claim processed correctly based on the routine eyewear benefit.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the Plan has not submitted medical records for us to review to determine if the eyeglasses were prescribed due to cataract surgery. Therefore, we decided that the Plan has to pay for standard frames and lenses, as defined by Medicare, provided on July 2, 2021.
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 pay for the supplies rendered on April 13, 2021.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure codes A4558 and A4556 are not separately payable.

The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of P are bundled/excluded codes. 

We looked at the file and Medicare rules. Billed procedure code A4558 (electrodes, pair) and A4556 (conductive gel or paste) have a status indicator of P and no separate Medicare payment. Therefore, we decided that the Plan does not have to pay for the supplies rendered on April 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral complete series x-ray (D0210) provided on August 23, 2021 and full mouth debridement (D4355) provided on September 9, 2021.

You asked the Plan to pay for the intraoral complete series x-ray and full mouth debridement. You say that you were experiencing a toothache and were desperate for services. You say that you are not able to afford the outstanding balance and payment should be reconsidered. The Plan denied your request. The Plan says an intraoral x-ray and full mouth debridement are only covered once every three plan years.

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, you also have a maximum benefit of one intraoral complete series x-ray and full mouth debridement every three plan years. The Plan paid for the intraoral complete series x-ray and full mouth debridement provided on March 8, 2019, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the intraoral complete series x-ray (D0210) provided on August 23, 2021 and full mouth debridement (D4355) provided on September 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin based composite for a posterior tooth (D2931) provided on July 14, 2021.
You asked the Plan to pay for the dental service. You say that the service was denied as not covered. You say that this procedure was scheduled and performed based off the benefit fax back summary that you received from the enrollee's plan. You also say that this service is listed as covered an should be paid at 80%. The Plan denied your request. The Plan says the resin based composite for a posterior tooth is not listed as a covered 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. Though the Plan offers a dental benefit in excess of Medicare coverage, the resin based composite for a posterior tooth is not among those covered under this benefit. The record shows that the benefit summary referenced is from 2017. The record also shows that the enrollee has changed plan's since then.
Therefore, we decided that the Plan does not have to pay for the resin based composite for a posterior tooth (D2931) provided on July 14, 2021.