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

 We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), panoramic x-ray (D0330), and adjunctive procedure (D9999) provided on June 10, 2021 by a Medicare opt out provider.  

You asked the Plan to pay for the problem focused limited oral evaluation, panoramic x-ray, and adjunctive procedure. You say that the voluntary dental benefit has nothing to do with Medicare and the provider's participation should not be a requirement in this case. The Plan denied your request. The Plan says you received these services from a provider who chose not to receive Medicare funds. The Plan also says that this treating provider opted out of Medicare effective February 15, 2016, to February 15, 2022.  

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 covered when they are received by a provider who has opted out of Medicare. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), panoramic x-ray (D0330), and adjunctive procedure (D9999) provided on June 10, 2021 by a Medicare opt out provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the complete series of intraoral x-rays (D0210) provided on July 26, 2021.  You asked the Plan to pay for the complete series of intraoral x-rays. You say that you were not informed of the frequency limitations for x-rays. You also say that you are on a low income and would like help covering this bill. The Plan denied your request. The Plan says benefits for this service have been satisfied and the frequency limitation has been exceeded. The Plan also says that you contacted the Plan on June 8, 2021 to review your benefits, and you were mailed the list of code-specific benefits along with their frequencies and limitations.  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, full mouth or panoramic x-rays share a frequency limitation of one procedure code every five years. The record shows that you received a complete series of intraoral x-rays (D0210) on October 15, 2020 and your full mouth or panoramic x-rays benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the complete series of intraoral x-rays (D0210) provided on July 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the 8 units of code Q4246 billed for use of Coretext or Protext provided on July 20, 2021.  You asked the Plan to pay for the 8 units of code A4246. You say that this should be paid. The Plan denied your request. The Plan says this is not supported.  The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided for each procedure code.  We asked our coding 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 8 units of code A4246 Our reviewer says that the number of units billed of this code are not supported. Our coding reviewer found per documentation "Protext Product code: PT200-25 Exp:03/25/2026 Size: 2.0ml Lidocaine Lot# 07-084-DK exp 1jul2021 Ethyl Chloride Lot#2212 Exp 01/2024". Documentation supports 2 ml given. Q4246 is per cc, therefore, 2 units should be billed for this service.   We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the 8 units of code A4246 have not been met. Therefore, we decided that the Plan does not have to pay for the 8 units of code Q4246 billed for use of Coretext or Protext provided on July 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug test (G0482) rendered by the out-of-network (OON) provider on July 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 drug test (G0482) rendered by the out-of-network (OON) provider on July 7, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital admission for the enrollee.

You asked the Plan to pay for the admission. You say that this should be paid for. The Plan denied your request. The Plan says the records indicate enrollment in a Medicare-certified hospice program.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for inpatient hospital admission for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve POV, group 1 standard, patient weight capacity up to and including 300 pounds (CPT code K0800), for the enrollee.  You asked the Plan to pre-approve the POV. You say that the POV is necessary. The Plan denied your request. The Plan says the requested service is not covered by Medicare or the health plan. The Plan states the power scooter was requested for the purpose of facilitating mobility outside of the home and it is not covered for this.  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 POV, group 1 standard, patient weight capacity up to and including 300 pounds (CPT code K0800), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a group 3 power wheelchair with single power option (K0856) and accessories.  

You asked the Plan to pre-approve a group 3 power wheelchair with single power option and accessories. You say that this device and its related accessories are medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.  

The Plan follows Medicare rules. Medicare rules say that a group 3 power wheelchair with single power option is subject to the criteria listed 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 a group 3 power wheelchair with single power option and accessories. Our reviewer says that the requested wheelchair is not medically reasonable and necessary. Our physician reviewer found that you are a 69-year-old female with a medical history including legal blindness, hereditary cerebellar ataxia unspecified with repeated falls with injuries and chronic lung disease who is requesting authorization for a power wheelchair. The documentation indicates that you are non-ambulatory due to your movement disorder and has suffered a recent shoulder injury. You do not require intermittent urinary catheterization and does not have any skin injuries due to pressure.    

In this case, you have a neurologic disorder with functional deficits. You meet the criteria for use of a group 3 wheelchair. However, the documentation does not indicate that you have any pressure injuries or requires intermittent catheterization of the bladder. Therefore, the power tilt seating system would not be medically necessary. This would indicate the single power option feature of the group 3 powered wheelchair would not be medically necessary as the power tilt seating system is a requirement for this specific wheelchair. Furthermore, the documentation indicates that the member is blind and would not be able to safely use a power mobility device.   

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 group 3 power wheelchair with single power option and accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair with single power option (K0856) and accessories.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve admission to a skilled nursing facility.  

You asked the Plan to pre-approve SNF care. You say that you need SNF care. The Plan denied your request. The Plan says rules for SNF care have not been met.  

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 that you do not have documented skilled nursing needs. In addition, you do not have documented skilled therapy needs. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of your condition. Your care needs, as a practical matter, can be 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 admission to a skilled nursing facility.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound provided on May 21, 2021.

You asked the Plan to waive the copayment for an ultrasound. You say that you are paying more money out-of-pocket
on an advantage plan than with original Medicare and you are unhappy with the Plan benefits. The Plan
denied your request. The Plan says the claims were processed correctly, and you are being charged the correct
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 $125
copayment for ultrasounds.

You have been asked to pay a $125 copayment for an ultrasound. An ultrasound falls 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 an ultrasound provided on May 21, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve nine (9) lymphedema physical therapy sessions.  

You asked the Plan to pre-approve lymphedema physical therapy sessions. The Plan denied your request. The Plan says it is not anticipated that coverage for ongoing skilled therapy could be authorized after six (6) additional visits because this is clearly maintenance therapy and maintenance therapy is not a covered benefit. Maintenance therapy is not considered to require the skills of licensed trained therapist, nor does Medicare cover the cost of those services if they are billed as skilled therapy.  

The Plan follows Medicare rules. Medicare rules say that when it is reasonable to assume that ongoing services could reasonably be carried out by the patient and/or appropriately trained caregiver(s), then the services are considered to be at a maintenance level of care and no longer require the skills of a qualified clinician.  

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 nine (9) lymphedema physical therapy sessions. Our reviewer says that lymphedema physical therapy sessions are not medically necessary. Our physician reviewer found that based on the medical records provided there is no documentation that the requested lymphedema physical therapy sessions meet the Medicare coverage criteria (Billing and Coding: Lymphedema Decongestive Treatment (A52959) - Coverage Requirements) as the services are considered to be at a maintenance level of care and no longer require the skills of a qualified therapist.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of nine (9) lymphedema physical therapy sessions have not been met. Therefore, we decided that the Plan does not have to pre-approve nine (9) lymphedema physical therapy sessions.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for the rotary wing air ambulance transport (A0431) and rotary wing air
mileage (A0436) provided on June 3, 2020.
You asked the Plan to pay for the rotary wing air ambulance transport and air mileage. You say that the
enrollee was transported to the closest available facility with needed capability to treat the enrollee. You also
say that there were no other resources available to transport the enrollee safely. The Plan denied your request.
The Plan says that these services were not medically necessary. The Plan also says that the enrollee was not
transported to the closest facility capable of providing the necessary services.
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. We found that the Plan failed to obtain records from the originating facility to
support that there was a closer facility actually able to accept the enrollee on this date of service. Therefore, we
decided that the Plan has to pay for the rotary wing air ambulance transport (A0431) and rotary wing air
mileage (A0436) provided on June 3, 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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a powered pressure reducing air mattress.  You asked the Plan to pre-approve a powered pressure reducing air mattress. You say that the requested mattress is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the coverage criteria have not been met.  The Plan follows Medicare rules. Medicare rules say that a powered pressure reducing air mattress is subject to the criteria listed 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 a powered pressure reducing air mattress. Our reviewer says that the requested item is not medically reasonable and necessary. Our physician reviewer found the records do not document that the enrollee has multiple stage 2 pressure ulcers located on the trunk or pelvis which have failed to improve over the past month, during which time he has been in a comprehensive ulcer treatment program or that he has large or multiple stage 3 or 4 pressure ulcer(s) on the trunk or pelvis or that he has had a myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis within the past 60 days.  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 powered pressure reducing air mattress have not been met. Therefore, we decided that the Plan does not have to pre-approve a powered pressure reducing air mattress.
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 treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  

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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a bone stimulator device (E0760).  

You asked the Plan to pre-approve the bone stimulator device. You say that the bone stimulator is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.  

The Plan follows Medicare rules. Medicare rules say that a bone stimulator is covered when there is a non-union of a fracture documented by a minimum of two sets of radiographs.   

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 bone stimulator device. Our reviewer says that the bone stimulator is not medically necessary. Our physician reviewer found the documentation provided does not show the presence of a non-union fracture.  

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 bone stimulator device have not been met. Therefore, we decided that the Plan does not have to pre-approve a bone stimulator device (E0760).
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Spiriva.  

You asked the Plan to pre-approve Spiriva. You say that the requested drug is medically necessary as the enrollee has severe asthma. The Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not covered under Medicare 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 Spiriva.   

Benefits for Spiriva 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 pay for the limited oral evaluation - problem focused (D0140) and crown - porcelain/ceramic (D2740) provided August 9, 2021.  You asked the Plan to pay for the limited oral exam and crown. You say that your dentist told you the services would be covered, and you cannot afford the cost. The Plan denied your request. The Plan says these services are 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 pay for the limited oral evaluation - problem focused (D0140) and crown - porcelain/ceramic (D2740) provided August 9, 2021.   Your complaint about the Plan not providing adequate dental coverage is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.