Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan does not have to provide coverage for a continuous glucose monitor for the enrollee.
You asked the Plan to provide coverage for a continuous glucose monitor. You say that a continuous glucose
monitor is medically necessary. The Plan denied your request. The Plan says all the required Medicare criteria
are not met. We overturned the Plans denial due to a lack of medical records in the file. The Plan
requested a reopen and submitted the required medical records.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that all the required
criteria for a continuous glucose monitor must be met for the device to be covered by Medicare.
Based on the medical records provided, the documentation indicates that the enrollee is not insulin-treated with
multiple (three of more) daily injections of insulin or a continuous subcutaneous insulin infusion (CSII) pump.
The records show the enrollee takes insulin once a day in the evening without variation in the dose. The
enrollee does not make frequent insulin treatment regimen changes. The enrollee takes the same dose of Lantus
(20 units) once each night.
Based on this information, we decided that Medicare rules for coverage of a continuous glucose monitor have
not been met. Therefore, we decided that the Plan does not have to provide coverage for a continuous glucose
monitor for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator.
You asked the Plan to pre-approve a portable oxygen concentrator. You say that this equipment is medically
necessary. The Plan denied your request. The Plan says Medicare coverage criteria were not met. We 
overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan says
that you were provided with a stationary oxygen concentrator and tubing for home use. The Plan also indicates
you refused the lighter replacement tanks offered by the Plan. The Plan noted that the appeal request indicates
the main reason for the request for a portable oxygen concentrator is for use outside of the home.
The Plan is correct in this case. 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 records show you stated you are referring to the portable concentrator that looks like a purse. You stated
you refused the tanks that came with the home unit because they were too heavy. However, you refused the
offer of lighter smaller tanks by the Plan. You stated the portable concentrator is more convenient to go to your
doctor's appointments.
You asked for this equipment for convenience and for use outside of the home. Although this item may be
helpful, neither Medicare nor the Plan covers equipment for use outside the home or for convenience.
Therefore, we decided that the Plan does not have to provide coverage for a portable oxygen concentrator.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that the enrollee is a fall risk and can only get around with supervision. You say that therapy is needed to rebuild strength and mobility so that the enrollee can get around independently. The Plan denied your request. The Plan says the enrollee has not had a change in
function that needs daily skilled therapy services. The Plan says that there are no daily skilled nursing needs noted. The Plan says that the enrollee's needs can be met at a lower level of care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications, had stable vital signs, and had clear lungs. The enrollee received physical therapy and occupational therapy. The enrollee was at a standby assist for functional mobility, including gait to 750 feet. The enrollee required varying assist with activities of daily living. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not meet the 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care provided on July 29, 2021.

You asked the Plan to waive the copayment for emergency care. You say that you feel that the facility you were at should have been able to do an electrocardiogram and feel that the Plan should pay for the charges. 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 $90 copayment for emergency care. 

You have been asked to pay a $90 copayment for emergency care. Emergency care falls within the emergency care 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 emergency care provided on July 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there is no documentation of a neurological disorder, myopathy, or a congenital skeletal diagnosis.

The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 

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 services. Our reviewer says that the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found the enrollee does not have a group 3 qualifying diagnosis of a mobility limitation that is due to a neurological condition, a myopathy, or a congenital skeletal deformity therefore the criteria for a Group 3 power wheelchair and accessories have not been met. 

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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a full upper immediate denture (D5130) to be provided by a participating provider.  You asked the Plan to pre-approve dentures. You say that the dentures that were made were made incorrectly. You say that they fit sideways. The Plan denied your request. The Plan says the benefit limit for dentures has already been exhausted.  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 dentures once every five years.  We looked at the file and Medicare rules. Evidence was provided to show that a set of dentures was provided on March 2, 2020. Based on this information, we decided that the Plan's rules for coverage of dentures have already been exhausted. Therefore, we decided that the Plan does not have to pre-approve a full upper immediate denture (D5130) to be provided by a participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided between 10:00 PM and 8:00 AM at 24-hour facility (99053) provided on April 30, 2021.

You asked the Plan to pay for the services provided between 10:00 PM and 8:00 AM at 24-hour facility. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code 99053 has a status indicator of B.

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 find that CPT code 99053 is not supported in the record. Specifically, CPT code 99053 has a status indicator of B. This means that payment for this CPT code 99053 is always bundled into the payment for another service or procedure. Based on this information, we decided that Medicare rules for coverage of the services provided between 10:00 PM and 8:00 AM at 24-hour facility have not been met. Therefore, we decided that the Plan does not have to pay for the services provided between 10:00 PM and 8:00 AM at 24-hour facility (99053) provided on April 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical placements of implant bodies: endosteal implants (D6010), bone grafts at time of implant placements (D6104), bone replacement grafts for ridge preservation (D7953), and one additional alveoloplasty in conjunction with extractions (D7310) provided on January 11, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the endosteal implants, bone grafts, bone replacement grafts, and additional alveoloplasty. You say that you say that you added dental coverage because you were told it was going to get better. You also say that the extractions should have been covered at 35% or so. The Plan denied your request. The Plan says the endosteal implants, bone grafts, and bone replacement grafts are not covered expenses under your dental plan. The Plan also says that your benefits for the additional alveoloplasty 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, the surgical placement of implant body: endosteal implant (D6010), bone graft at time of implant placement (D6104), and bone replacement graft for ridge preservation (D7953) are not among those covered under this benefit. The contract says that oral surgery is limited to two procedure codes per calendar year. The record shows that you received three alveoloplasties in conjunction with extractions (D7310 x3) on January 11, 2021, two of which were covered at the OON rate by the Plan, and your oral surgery benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the surgical placements of implant bodies: endosteal implants (D6010), bone grafts at time of implant placements (D6104), bone replacement grafts for ridge preservation (D7953), and one additional alveoloplasty in conjunction with extractions (D7310) provided on January 11, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the hernia repair services provided on May 20, 2021.

You asked the Plan to pay for the services provided. You say that the medical records support the use of the modifier. The Plan denied your request. The Plan says the billed code cannot be verified.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.

In this case, the CPT Code Manual definition of code 49561 is repair initial incisional or ventral hernia; incarcerated or strangulated. We looked at the file and the rules. The medical records show that the hernia repair was performed during a cholecystectomy laparoscopy procedure. If a hernia repair is performed at the site of an incision for an open or laparoscopic abdominal procedure, the hernia repair is not separately reportable. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the hernia repair services provided on May 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit with and otolaryngologist on August 20, 2021.

You asked the Plan to waive the copayment for the otolaryngology office visit. You say that you believe you are being charged for visits you did not have. The Plan denied your request. The Plan says you were charged this copayment correctly.

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 $35 copayment for physician/practitioner services in a specialist's office. 

You have been asked to pay a $35 copayment for the otolaryngology office visit. We looked at the medical records and confirmed that you did receive office visit services on August 20, 2021. The specialist copayment applies to all visits to a specialist's office. 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 the office visit with and otolaryngologist on August 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services (procedure code 70450) provided to the enrollee on August 14, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says this service cannot be unbundled.
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, we have confirmed that code 70450 is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for imaging services (procedure code 70450) provided to the enrollee on August 14, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gel-One.
You asked the Plan to pre-approve Gel-One. You say that these injections would benefit the patient. The Plan
denied your request. The Plan says the requirements for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that viscosupplementation therapy for the knee via
intra-articular injections of hyaluronic preparations will be considered medically reasonable and necessary
when the patient has failed at least three months of conservative therapy.
We looked at the file and Medicare rules. The records do not document that the enrollee has failed at least 3
months of conservative therapy. Based on this information, we decided that Medicare rules for coverage of
Gel-One have not been met. Therefore, we decided that the Plan does not have to pre-approve Gel-One.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve twelve (12) additional physical therapy (PT) visits (97164) provided on August 30, 2021.
You asked the Plan to pre-approve additional PT visits. You say that the requested additional PT visits are medically necessary. The Plan denied your request. The Plan says the requested additional PT visits do not meet criteria.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 additional PT visits. Our reviewer says that skilled services were not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found there is no documentation that the specialized skill, knowledge and judgment of a qualified therapist is required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. The enrollee appears to have improved with therapy including making great progress with his range of motion, activities, ambulation and home exercise plan; he continues to have limitations with strength and endurance. Further utilization of the home exercise program appears appropriate at this point to address his needs with strengthening and endurance. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve twelve (12) additional physical therapy (PT) visits (97164) provided on August 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair and accessories (K0823, E0973, E2365).
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary, as a manual wheelchair cannot be used on the carpet. The Plan denied your request. The Plan says there is no documentation of any significant postural instability or upper body disease.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.
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 wheelchair. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found there is no detailed neuromuscular exam of the upper extremities. There is no detailed home assessment with measurements of doorways indicating that the requested wheelchair will be able to maneuver safely within the home and that it will significantly improve MRADL performance in the home. As the criteria for the requested K0823 wheelchair have not been met the wheelchair is not medically necessary the requested accessories are also not medically 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 wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair and accessories (K0823, E0973, E2365).
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 full mouth debridement to enable a comprehensive oral evaluation and diagnosis on a subsequent visit (D4355) provided August 3, 2021.

You asked the Plan to pay for the limited oral exam and full mouth debridement. You say that these services were necessary, and the booklet says it is covered. 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 full mouth debridement to enable a comprehensive oral evaluation and diagnosis on a subsequent visit (D4355) provided August 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve level 4 radiofrequency ablation coded as 64635 and 64636.

You asked the Plan to pre-approve level 4 radiofrequency ablation. You say that the enrollee had a previous radiofrequency ablation that provided him with 80% pain relief for close to a year. This procedure is very beneficial to him. The Plan denied your request. The Plan says there is not enough evidence to support the need for a repeat radiofrequency ablation at four levels, therefore, 2 levels are approved as meeting the criteria.

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 level 4 radiofrequency ablation. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, the last radiofrequency ablation procedure provided 70% pain relief for only 2 months. In addition, there is no specific clinical rationale for the requested 4-level RFA. The review has determined that the requested 4-level radiofrequency ablation does not meet the coverage criteria and is not medically necessary or reasonable. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of level 4 radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve level 4 radiofrequency ablation coded as 64635 and 64636.