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

 We decided that the Plan does not have to pay for the four two dimensional (2D) oral/facial photographic images (D0350 x4) and panoramic x-ray (D0330) provided on August 31, 2021.  You asked the Plan to pay for the 2D oral/facial photographic images and panoramic x-ray. You say that you did not receive an estimate prior to having these x-rays taken. You also say that you are refusing to pay for these services because you feel they were extraneous and would have refused them if you had known there would be an additional cost. The Plan denied your request. The Plan says the 2D oral/facial photographic image is not a covered expense under your dental plan. The Plan also says that your benefits for the panoramic x-ray have been satisfied and the frequency limitation has been exceeded.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage, 2D oral/facial photographic image (D0350) is not among those covered under this benefit. The contract says that 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 on this same date of service, August 31, 2021, 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 four two dimensional (2D) oral/facial photographic images (D0350 x4) and panoramic x-ray (D0330) provided on August 31, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve external upper limb tremor stimulator of the peripheral nerves of the wrist (K1018) and monthly supplies for use of device (K1018).  

You asked the Plan to pre-approve Cala Trio nerve stimulator device. You say that the company told you that they were working on getting approval as a medical device manufacturer from Medicare, but it had not happened yet and being desperate you are paying for the device. The Plan denied your request. The Plan says this device is experimental and/or investigative. Medical studies have not proven that this device is helpful for treatment of your health problem.  

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. Based on this information, we decided that Medicare rules for coverage of Cala Trio nerve stimulator device have not been met. Therefore, we decided that the Plan does not have to pre-approve external upper limb tremor stimulator of the peripheral nerves of the wrist (K1018) and monthly supplies for use of device (K1018).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve porcelain crowns (D2740) and core build up (D2950) for teeth # 6, 11, 22, 23, and 27.  You asked the Plan to pre-approve the dental services. You say that the services are necessary. The Plan denied your request. The Plan says porcelain crowns are not listed as covered services. The Plan also says that core build up are not listed as covered services 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 requested porcelain crowns and core build up are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve porcelain crowns (D2740) and core build up (D2950) for teeth # 6, 11, 22, 23, and 27.
Appeal type: DME/ Orthotics
Decision: Unfavorable

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

 We decided that the Plan does not have to pay for the inpatient hospital services provided from September 24, 2020, through September 27. 2020, billed with secondary diagnosis code J96.01.  You asked the Plan to pay for the inpatient services as billed. You say that this claim was billed correctly. The Plan denied your request. The Plan says the DRG billed was not supported as the secondary diagnosis was not correct.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.    In this case, you billed the inpatient services provided with secondary diagnosis code J96.01, defined as acute respiratory failure with hypoxia. 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 inpatient services as billed. Our reviewer says that the secondary diagnosis code J96.01 is not supported by the records. Our physician reviewer found there was no mention of acute respiratory failure per the emergency room, history and physical, and/or discharge summary notes. Documentation did not support treatment consistent with acute respiratory failure including high flow oxygen 5 liters per minute or more, provision of BiPAP and/or mechanical ventilation. The review has determined that the documentation did not support the reported secondary diagnosis code of J96.01.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services provided from September 24, 2020, through September 27. 2020, billed with secondary diagnosis code J96.01.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve pneumatic compression device (E0651) and segmental pneumatic appliance (E0667) to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve the pneumatic compression device and appliance. You say that this appeal process has caused an unnecessary delay in the enrollee receiving treatment. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.  The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services.  Therefore, we decided that the Plan does not have to pre-approve pneumatic compression device (E0651) and segmental pneumatic appliance (E0667) to be provided by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to provide coverage for additional routine transportation trips.  

You asked the Plan to provide coverage for additional routine transportation trips. The Plan denied your request. The Plan says you have used a total of 44 trips, exhausting your benefit from January 7, 2021, through June 1, 2021. A review of your claims show that the benefit maximum was reached on May 6, 2021.  

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 44 one-way trips per year.   

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to provide coverage for additional routine transportation trips.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pay for diphenhydramine HCL, up to 50MG injection (CPT code J1200) provided to the enrollee on March 17, 2021.  

You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. The Plan says J2100 remains not supported and the medical records submitted indicate that Diphenhydramine HCl, 50 mg, oral, was administered. Healthcare Common Procedure Coding System (HCPCS) J1200, Injection, diphenhydramine HCl, up to 50 mg, was billed. The Plan states there is a more appropriate HCPCS code Q0163 that should be used to bill for the service provided.  

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 the service. Our reviewer found the documentation submitted was reviewed and it does not meet criteria. Per documentation "8:50 Benadryl 50 mg PO".  J1200 is the incorrect code to report for this procedure, and therefore would not be covered.  

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 service have not been met. Therefore, we decided that the Plan does not have to pay for diphenhydramine HCL, up to 50MG injection (CPT code J1200) provided to the enrollee on March 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a surgical access to an implant body (D6011), custom fabricated abutment (D6057) and an abutment supported porcelain/ceramic crown (D6058).  You asked the Plan to pre-approve dental services. You say that you are waiting for information that this crown will be covered. The Plan denied your request. The Plan says this type of service is not eligible due to being a non-covered benefit. The crown is to be fabricated on an implant which is considered an artificial tooth (not a natural tooth) therefore making this a cosmetic procedure and non-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 pre-approve a surgical access to an implant body (D6011), custom fabricated abutment (D6057) and an abutment supported porcelain/ceramic crown (D6058).
Appeal type: Imaging
Decision: Favorable

 We decided that the Plan has to pre-approve a prostate-specific membrane antigen (PSMA) positron emission tomography (PET) scan.  

You asked the Plan to pre-approve the requested services. You say that the scan would be more likely to detect metastasis. The Plan denied your request. The Plan says that PET scans as an initial anti-tumor treatment strategy is not covered.  

The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically necessary.   

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 requested services. Our physician reviewer found that the National Comprehensive Cancer Network (NCCN) guidelines state that PSMA-PET has increased sensitivity and specificity for detecting micrometastatic disease as compared to conventional imaging both at time if initial staging and for the work-up of recurrence. The NCCN no longer feel that conventional imaging is a necessary prerequisite to PSAM-PET and the PSMA PET/CT or PSMA/MRI can serve as equally effective, if not more effective, front-line imaging. Notably, the coverage criteria require that PET scans be used to determine eligibility of an invasive procedure. If the enrollee has metastatic disease as detected by PET, the treatment plan would change, without the need for aggressive prostate-directed radiation therapy. The PSMA PET requested for this enrollee is considered superior to other PET modalities in terms of sensitivity and specificity. Therefore, the requested testing is considered medically reasonable and necessary.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan has to pre-approve a prostate-specific membrane antigen (PSMA) positron emission tomography (PET) scan.   

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 foot orthotics (L3010, L3410).  You asked the Plan to pre-approve foot orthotics. You say that the shoe inserts are medically necessary. The Plan denied your request. The Plan says this item is not a covered benefit.  Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.    Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics (L3010, L3410).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging, lower extremity other than joint (73719) to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the MRI. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging, lower extremity other than joint (73719) to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with accessories.  You asked the Plan to pre-approve power wheelchair. You say that you were provided with a basic wheelchair that is the only wheelchair you have ever received. The Plan denied your request. The Plan says the denial of authorization for this device is correct, because this services a duplicate purpose to the power wheelchair you already have and your current wheelchair does not need to be replaced.  The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary.  The file shows that you have a power wheelchair. A new power wheelchair serves the same purpose as your current power wheelchair. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair with accessories.
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 6, 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 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the cone beam CT capture and endodontic therapy.  

You asked the Plan to pay for the cone beam CT capture and endodontic therapy. You say that your molar broke and they need to do a root canal to put the crown on. You say that you are in pain and the temporary filling will come out if the root canal isn't done soon. The Plan denied your request. The Plan says the services are not covered 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 cone beam CT capture and endodontic therapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Kate Farms oral nutrition supplement (B4150).  

You asked the Plan to pre-approve oral nutrition supplement. You say that the enrollee struggles to eat due to radiation enteritis and using Kate Farms allows her to maintain weight and strength while managing the side effects of cancer treatment. The formula is too expensive to purchase out of pocket. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria.  

The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation.  

The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan does not have to pre-approve Kate Farms oral nutrition supplement (B4150).
Appeal type: DME/ Orthotics
Decision: Unfavorable

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

 We decided that the Plan does not have to pay for the therapeutic parenteral drugs (D9612) provided on June 10, 2021.  You asked the Plan to pay for the therapeutic parenteral drugs. You say that the Plan advised that you could be seen by this treating provider and they would accept your insurance. The Plan denied your request. The Plan says this service is not a covered expense under your dental 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.  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 therapeutic parenteral drugs (D9612) provided on June 10, 2021.