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

We decided that the Plan does not have to pre-approve deep sedation/general anesthesia (D9222, D9223) and two or more administrations of therapeutic parenteral drugs (D9612).

You asked the Plan to pre-approve the dental anesthesia and drug services. You say that these services are necessary for your upcoming dental procedure. 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 deep sedation/general anesthesia (D9222, D9223) and two or more administrations of therapeutic parenteral drugs (D9612).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Dexcom G6 transmitter (K0553).

You asked the Plan to pre-approve a Dexcom G6 transmitter. You say that the requested item is a necessity for the enrollee's care. The Plan denied your request. The Plan says rules for continuous glucose monitors have not been met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan. 

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a Dexcom G6 transmitter have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 transmitter (K0553).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.

You asked the Plan to pre-approve continued services. You say that the enrollee should not be discharged yet.
The Plan denied your request. The Plan says the enrollee's care can be provided by a non-skilled person.

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.

Continued services beyond September 7, 2021, were requested. 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 services. Our physician reviewer found that from a nursing perspective, the
enrollee received oral medications and had stable vital signs. She was seen by Orthopedic surgery in consult for
possible osteomyelitis on left ankle x-ray who had low clinical concern for any infection but further work-up
was recommended. There are no identifiable skilled nursing service needs. Regarding rehabilitation services,
the enrollee was at a minimal to contact guard assist level with functional mobility. She required varying assist
with activities of daily living. There are no identifiable skilled therapy service needs. She does not require
skilled nursing or therapy services on a daily basis. She does not meet severity of illness or intensity of service
criteria for 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 services have not been met. Therefore, we decided that the Plan does
not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve repeat lumbar facet injections.

You asked the Plan to pre-approve lumbar facet injections (64493, 64494). You say that the enrollee did receive 70-75% relief from the initial lumbar face injection. The Plan denied your request. The Plan says the enrollee did not receive 80% relief from the combined injections.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We looked at the file and Medicare rules. The record shows the enrollee only received 70-75% relief. Based on this information, we decided that Medicare rules for coverage of lumbar facet injections (64493, 64494) have not been met. Therefore, we decided that the Plan does not have to pre-approve repeat lumbar facet injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve deep sedation/general anesthesia (D9222) and sinus augmentation with bone or bone substitutes (D7951).

You asked the Plan to pre-approve general anesthesia and sinus augmentation. You say that these services are necessary, and you will not be able to afford them without help. 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 deep sedation/general anesthesia (D9222) and sinus augmentation with bone or bone substitutes (D7951).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the endodontic therapy (D3330) provided on April 28, 2021 by an OON provider.

You asked the Plan to pay more for the endodontic therapy. You say that you tried to find an in-network dentist to provide this service, but this treating provider was the closest in your area. You also say that the in-network providers you found only worked part-time and had bad reviews. The Plan denied your request. The Plan says your liability was applied correctly because this service was rendered OON, the Plan pays according to a maximum allowable fee schedule and you are responsible for all fees in excess of this amount from the billed amount. The Plan also says that since the provider was OON, the difference of billed amount and allowed amount also became your responsibility.

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 are responsible for a 50% coinsurance plus the difference between the billed amount and allowed amount for dental services received OON. Therefore, we decided that the Plan does not have to pay more for the endodontic therapy (D3330) provided on April 28, 2021 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two custom fabricated abutments (D6057 x2) and two abutment supported porcelain fused to metal crowns (D6061 x2) provided on May 6, 2021.

You asked the Plan to pay for the custom fabricated abutments and abutment supported porcelain fused to metal crowns. You say that a Plan representative advised that these services should be covered in full. The Plan denied your request. The Plan says these services are not covered benefits under your dental plan. The Plan also says that prior to these services being rendered your provider submitted a pre-determination approval, which was denied by the Plan and you were informed that these services would not be covered.

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 pay for the two custom fabricated abutments (D6057 x2) and two abutment supported porcelain fused to metal crowns (D6061 x2) provided on May 6, 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 enrollee's condition is worse. The Plan denied your request. The Plan says the enrollee does not require an intensive multidisciplinary approach to daily therapy.

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 physician reviewer found that the enrollee has a past medical history of stroke with left hemiplegia who is living at home with residual weakness and trouble ambulating. His medical problems are stable. There are no complex nursing needs.

He does not require treatment by multiple therapies in an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. 

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the office visit (99204) provided on
March 10, 2021.

You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to the service provided.

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 services provided by an out-of-network specialist. 

You have been asked to pay $35.39 (Plan allowed amount of $176.96 x 20% coinsurance) for the out-of-network specialist visit provided.

This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the office visit (99204) provided on March 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve removal of torus mandibularis (D7473) for all four mouth quadrants.

You asked the Plan to pre-approve the dental procedures. You say that these services are necessary for you to get dentures. The Plan denied your request. The Plan says this service is not covered by your dental benefit.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve removal of torus mandibularis (D7473) for all four mouth quadrants.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on August 13, 2020.

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 code 36224 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.

In this case, the CPT Code Manual definition of code 36224 is selective catheter placement, internal carotid artery, unilateral, with angiography of the ipsilateral intracranial carotid circulation and all associated radiological supervision and interpretation, includes angiography of the extracranial carotid and cervicocerebral arch, when performed.

We find that CPT code 36224 is not supported in the medical record. Specifically, there is no documentation of selective catheter placement into unilateral internal carotid artery. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the surgical services rendered on August 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional massage therapy.

You asked the Plan to pre-approve additional massage therapy. You say that you are in need of this therapy
because of current physical therapy for arm and neck range exercises, bilateral shoulder replacements with
ongoing muscle rehabilitation needed, particularly on the right side and swelling of right arm and hand over
more than a year. The Plan denied your request. The Plan says the Plan has already approved 10 massage
therapy visits and no additional visits can be allowed.

The Plan contract covers alternative therapies not covered by Medicare, which includes 10 massage therapy
visits by a licensed massage therapist. Additional visits are not covered.

We looked at the file and Medicare rules. The file shows that you have already been approved for 10 massage
therapy visits. The Plan benefit covers 10 massage therapy visits, and no additional visits are covered.
Therefore, we decided that the Plan does not have to pre-approve additional massage therapy.
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 you cannot walk a short distance without assistance. The Plan denied your request. The Plan says you do not need to see a rehab doctor three times a week, or an intensive team to oversee care.

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 physician reviewer found that you were admitted to the acute care hospital for poly neuropathy associated with chemotherapy. Your medical problems are stable. The complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), prophylaxis (D1110), bitewing images (D0274), periapical images (D0220 and D0230), and unspecified preventive procedure (D1999) provided by an out-of-network dentist on February 9, 2021.

You asked the Plan to pay for dental services. You say that your benefits state that you have $0 copayment for exams, cleanings, X-Rays, and fluoride for an out-of-network dental provider. The Plan denied your request. The Plan says the denial of payment for these services is correct, because the Plan has paid up to the allowed amount for dental codes D0120, D1110, D0274, D0220, and D0230 so you are responsible for any amount beyond the Plan's payment, and because dental code D1999 is not covered by the Plan.

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 dental services received from an out-of-network dentist up to a certain amount. You may be responsible for billed charges above what the Plan pays, even for services with $0 copayment. The Plan does not cover dental service D1999. 

We looked at the file, the Plan's rules, and Medicare's rules. The Plan paid up to its allowed amount for dental codes D0120, D1110, D0274, D0220, and D0230. This dentist is out-of-network with the Plan; therefore, you may be responsible for any charges beyond what the Plan paid for these codes. Dental code D1999 is not covered by the Plan. Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation (D0120), prophylaxis (D1110), bitewing images (D0274), periapical images (D0220 and D0230), and unspecified preventive procedure (D1999) provided by an out-of-network dentist on February 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a genicular nerve block.

You asked the Plan to pre-approve a genicular nerve block.. The Plan denied your request. The Plan says this is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a genicular nerve block. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has knee pain secondary to degenerative joint disease and rheumatoid arthritis (RA). She is status post cortisone injections and viscosupplementation. Genicular nerve blocks are not indicated for pain related to RA. 

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 genicular nerve block. have not been met. Therefore, we decided that the Plan does not have to pre-approve a genicular nerve block.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for filling (D2391) provided on April 9, 2021.

You asked the Plan to pay for the dental service. You say that you were not properly notified that your new plan meant that everything changed. You say that you did not know that the dentist you have been seeing for years was out of network. You say that your dentist was not aware either. You also say that you feel you should not be responsible for this claim. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan also says that services performed out of network are not covered.

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 and the filling is listed as covered, dental services performed out of network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for filling (D2391) provided on April 9, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve outpatient mental health services with a provider who has opted out of Medicare.

You asked the Plan to pre-approve outpatient mental health services. You say that this request is medically necessary. The Plan denied your request. The Plan says this provider is not a Medicare approved provider.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. 

The services at issue in this appeal are to be provided in a non-urgent, non-emergent situation by a provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pre-approve outpatient mental health services with a provider who has opted out of Medicare.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the chemotherapy administration
(96402 x 2) and the Degarelix injection (J9155) provided on November 18, 2020.
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to the services provided.
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 each Medicare-covered
Part B drug; for the administration of that drug, you will pay the cost-sharing that applies to primary care
provider services, specialist services, or outpatient hospital services. Additionally, you pay a 20% coinsurance
for each Medicare-covered chemotherapy drug and the administration of that drug.
You have been asked to pay $206.04 (Plan allowed amount of $952.80 x 20% coinsurance=$190.56) for the
Medicare Part B drug injection and (Plan allowed amount of $77.40 x 20% coinsurance=$15.48) for the
chemotherapy administration provided. This means that you have been asked to pay the correct amount based
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the
chemotherapy administration (96402 x 2) and the Degarelix injection (J9155) provided on November 18, 2020.