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

We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2311, E2313, E2377, K0108x2) for the enrollee.

You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied your request. The Plan says the upper limb strength and function are adequate for the member to be able to control the power options using their own switches which are included in the allowance of these power options.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the accessories. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the K0108 bag holder and hooks are not medically necessary per Social Security Act, Section 1862 (a)1(A) and the 42 CFR 411.15(k) as Medicare does not pay for any items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. In terms of E2311, E2313, and E2377, the enrollee does not require non-proportional input devices (e.g., sip and puff, head array, etc.). The enrollee does not require a separate display (i.e., for alternate control devices), other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. The enrollee has 3 power options of tilt, recline, and power elevating leg rests but the enrollee does not need to control the power options through a joystick. The enrollee's right upper extremity strength supports that the patient can control any power options through their own switches. 

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 accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2311, E2313, E2377, K0108x2) for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport (A0428, A0425) provided on August 8, 2021.

You asked the Plan to pay for ambulance service, basic life support, non-emergency transport. The Plan denied your request. The Plan says the ambulance transport was not medically necessary.

Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 

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 ambulance service, basic life support, non-emergency transport. Our reviewer says that the ambulance transport was not medically necessary. Our physician reviewer found that the enrollee is an 84-year-old male with dementia who was transported via ambulance back to a nursing facility following hospital assessment following syncope and fall. He was reported as having weakness. His vitals were stable. He was confused but oriented to person. He was transported via stretcher due to fall risk. He did not require treatment during transport. The documentation does not support that other means of transport, such as stretcher van, were contraindicated for this enrollee.

The documentation does not support that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully equipped ambulance can provide for safe transport. The documentation does not support that the ambulance transport on August 8, 2021 was medically reasonable and necessary for the enrollee. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ambulance service, basic life support, non-emergency transport have not been met. Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport (A0428, A0425) provided on August 8, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay more for the lenses provided on August 11, 2021.

You asked the Plan to pay more for the lenses. You say that you have not used your covered benefits and most items listed were paid by you. You say that the file should be corrected, and the vendor should be paid. The Plan denied your request. The Plan says that the benefit for polycarbonate lenses, photochromatic and anti-reflective coating exhausted because the plan covered progressive lenses.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers up to $200 per year for eyewear, which includes both frames and lenses combined. 

We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for additional coverage of the lenses have been met. Specifically, the Evidence of Coverage says the Plan will pay $200 toward lenses and it does not state that lens upgrades are excluded from coverage. Therefore, we decided that the Plan has to pay up to $200 for the lenses provided on August 11, 2021.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the CardioMEMS implantation procedure for the enrollee.

You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says this is considered experimental, investigational, and unproven.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee has class III NYHA heart failure and has been hospitalized recently for heart failure exacerbation. The enrollee's body mass index is 49. The record does not indicate the enrollee's chest circumference. The elements of the coverage criteria are not satisfied. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the CardioMEMS implantation procedure for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve manual wheelchair repair including associated accessories to be provided by an out-of-network provider.

You asked the Plan to pre-approve the out-of-network services. You say that the services are necessary. The Plan denied your request. The Plan says they confirmed with an in-network durable medical equipment (DME) provider; Klingensmith Healthcare, they can provide the wheelchair accessories and can provide the DME supply once a referral is sent to them. The Plan also confirmed they bill the insurance company prior to billing the enrollee and the enrollee is responsible to provide the enrollee's insurance card for billing purposes.

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 manual wheelchair repair including associated accessories to be provided by an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a radiofrequency ablation of genicular nerve branches (64624) provided on May 26, 2021.
You asked the Plan to pay for a radiofrequency ablation procedure. You say that the services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met because the services at issue are experimental/investigational.
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a radiofrequency ablation procedure have not been met.
Specifically, the case record does not contain documentation to support medical necessity for the services at issue. Therefore, we decided that the Plan does not have to pay for a radiofrequency ablation of genicular nerve branches (64624) provided on May 26, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab services you received on August 10, 2021.
You asked the Plan to waive the copayment for the lab services. You say that you had to have three blood draws to complete the original one bloodwork order. You said that if enough blood had been drawn at your July 9, 2021, you would not have had to have additional lab services. 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 $5 copayment for lab services. You have been asked to pay a $5 copayment for the lab services. This copayment applies regardless of the reason for the lab services. 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 lab services you received on August 10, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (81162, 81194, 81206, 81235, 81292, 81295, 81298, 81301, 81309, 81317, 81321, 81402) provided on April 13, 2021.
You asked the Plan to pay for laboratory services. You say that this is supported in the records. The Plan denied your request. The Plan says this was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS).
We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (81162, 81194, 81206, 81235, 81292, 81295, 81298, 81301, 81309, 81317, 81321, 81402) provided on April 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller and two or more power seating system motors (E2311) and manual swingaway (E1028).

You asked the Plan to pre-approve an electronic connection between wheelchair controller and two or more power seating system motors and manual swingaway. You say that the items are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan follows Medicare rules. Medicare rules say that wheelchair accessories are covered when specific criteria are met. 

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 an electronic connection between wheelchair controller and two or more power seating system motors and manual swingaway. Our reviewer says that the items are not medically necessary. Our physician reviewer found records document that you have 3+/5 right upper extremity strength and is independent with dressing, grooming, bathing and feeding thus indicating you have adequate upper extremity strength and function to operate the wheelchair's power options with their own switches and thus indicating that the electronic connection (E2311) does not meet criteria for approval. The approved residual limb support system (E1020) already includes a swing away system, thus the additional manual swing away mount (E1028) does not meet criteria for approval. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an electronic connection between wheelchair controller and two or more power seating system motors and manual swingaway have not been met. Therefore, we decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller and two or more power seating system motors (E2311) and manual swingaway (E1028).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis (D1110) provided on January 13, 2021.

You asked the Plan to pay for the dental service. You say that your coverage was effective January 1, 2021. You also say that this service should be covered. The Plan denied your request. The Plan says prophylaxis is covered once every 6 months. The Plan also says the frequency limit 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 and prophylaxis is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for prophylaxis that you received on August 10, 2020, less than 6 months before. Therefore, we decided that the Plan does not have to pay for the prophylaxis (D1110) provided on January 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acute inpatient hospital care to be provided with a total shoulder arthroplasty procedure.
You asked the Plan to pre-approve acute inpatient hospital care. You say that these services are medically necessary. The Plan denied your request. The Plan says they have agreed to pre-approve the requested shoulder arthroplasty procedure (23472); however, the subsequent inpatient hospital care is not medically necessary in this case.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the record does not document that the treating physician has a reasonable expectation of a length of stay spanning 2 or more midnights following this procedure. The enrollee may be admitted for observation. The elements of the coverage rule for inpatient care are not satisfied. The requested service is not recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve the acute inpatient hospital care to be provided with a total shoulder arthroplasty procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment and coinsurance for a primary care visit, annual physical exam, electrocardiogram (EKG), and alcohol screening provided on May 26, 2021.
You asked the Plan to waive the copayment for the primary care visit, annual physical exam, EKG, and alcohol screening. You say that you were not aware of any costs for your appointment. The Plan denied your request. The Plan says the correct copayment and coinsurance was applied.
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 $40 copayment for each out-of-network (OON) primary care (PCP) visit. Your contract with the Plan also clearly says that you must pay a 40% coinsurance for one out-of-network (OON) annual physical exam per year. Your contract with the Plan also clearly says that you must pay a 40% coinsurance for each out-of-network (OON) electrocardiogram (EKG). Your contract with the Plan also clearly says that you must pay a 40% coinsurance for one out-of-network (OON) alcohol misuse screening per year. You have been asked to pay a $40 copayment for the primary care visit. Primary care visits fall within the Physician/Practitioner Services, Including Doctor's Office Visits benefit category. You have also been asked to pay $66.09, which is 40% of the allowed amount for the annual physical exam ($165.22 allowed x 40% coinsurance = $66.09). You have also been asked to pay $5.80, which is 40% of the allowed amount for the EKG ($14.49 allowed x 40% coinsurance = $5.80). You have also been asked to pay $7.28, which is 40% of the allowed amount for the alcohol screening ($18.19 allowed x 40% coinsurance = $7.28). The total for your visit is $119.17. 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 a primary care visit, annual physical exam, electrocardiogram (EKG), and alcohol screening provided on May 26, 2021.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay 50% of the billed amount for the endodontic therapy. We decided that the Plan does not have to pay in full for the endodontic therapy.

You asked the Plan to pay more for the endodontic therapy. You say that you feel that you are owed a refund. The Plan says that this claim processed correctly assessing the appropriate cost share per your 2021 Evidence of Coverage, since you had an authorization on file for the out-of-network provider.

We decided that the Plan has to pay 50% of the billed amount for the endodontic therapy.

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 record shows that you were given prior approval to be treated by an out-of-network (OON) provider. The 2021 Evidence of Coverage states that you will be responsible for a 50% coinsurance for supplemental comprehensive dental services, including root canals. The EOC does not clearly state that if prior approval is given to be treated OON, you will be responsible for more than the 50% coinsurance for the provided service. You reasonably believed 50% of this service would be covered by the Plan because you were approved to be treated by the OON provider. Therefore, we decided that the Plan has to pay 50% of the billed amount for the endodontic therapy.

We also decided that the Plan does not have to pay in full for the endodontic therapy.

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 for supplemental comprehensive dental services. Therefore, we decided that the Plan does not have to pay in full for the endodontic therapy.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intravenous moderate (conscious) sedation/analgesia- first 15 minutes (D9239), intravenous moderate (conscious) sedation/analgesia - each subsequent 15 minute increment (D9243), bone replacement graft for ridge preservation - per site (D7953) and extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140) provided September 27, 2021, and the prophylaxis - adult (D1110) and periodic oral evaluation - established patient (D0120) provided October 28, 2021.
You asked the Plan to pay for the anesthesia, bone replacement graft, tooth extraction, dental cleaning and periodic oral exam. You say that you would like the services covered. The Plan denied your request. The Plan says you have exceeded your dental benefit maximum.
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 supplemental dental services up to a $550 dental maximum. We looked at file and Medicare rules. The Plan provided documentation showing that at the time of your dental services on September 27, 2021, you had $8 remaining in your dental benefit. This $8 was applied towards your tooth extraction. The remaining costs on September 27, 2021, and October 28, 2021 are not covered. Therefore, we decided that the Plan does not have to pay for the intravenous moderate (conscious) sedation/analgesia- first 15 minutes (D9239), intravenous moderate (conscious) sedation/analgesia - each subsequent 15 minute increment (D9243), bone replacement graft for ridge preservation - per site (D7953) and extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140) provided September 27, 2021, and the prophylaxis - adult (D1110) and periodic oral evaluation - established patient (D0120) provided October 28, 2021.