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

We decided that the Plan does not have to pre-approve surgical placement of implant body: endosteal implant
(D6010), surgical access to an implant body (second stage implant surgery) (D6011), bone graft at time of
implant placement (D6104), radiographic/surgical implant index, by report (D6190), diagnostic casts (D0470),
provisional implant crown (D6085), custom fabricated abutment - includes placement (D6057), abutment
supported porcelain fused to metal crown (high noble metal) (D6059), osseous, osteoperiosteal, or cartilage
graft of the mandible or maxilla - autogenous or nonautogenous, by report (D7950), and sinus augmentation via
a vertical approach (D7952). You asked the Plan to pre-approve the endosteal implant and placement of implant, bone graft,
radiographic/surgical implant index, diagnostic casts, provisional implant crown, custom fabricated abutment,
abutment supported crown, facial surgery and sinus augmentation. You say that these services are medically
necessary. The Plan denied your request. The Plan says these services are not covered under the enrollee's
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 pre-approve
surgical placement of implant body: endosteal implant (D6010), surgical access to an implant body (second
stage implant surgery) (D6011), bone graft at time of implant placement (D6104), radiographic/surgical
implant index, by report (D6190), diagnostic casts (D0470), provisional implant crown (D6085), custom
fabricated abutment - includes placement (D6057), abutment supported porcelain fused to metal crown (high
noble metal) (D6059), osseous, osteoperiosteal, or cartilage graft of the mandible or maxilla - autogenous or
nonautogenous, by report (D7950), and sinus augmentation via a vertical approach (D7952).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Crutch substitute (E0118).
You asked the Plan to pre-approve a Crutch substitute. You say that you would like the Plan to reconsider their
denial. The Plan denied your request. The Plan says a crutch substitute coded as E0118 is not covered by
Medicare or the Plan.
The Plan must follow Medicare rules. Medicare rules say that there is insufficient published clinical literature
demonstrating safety and effectiveness in the Medicare population to establish the medical necessity for crutch
substitutes (E0118). Therefore, we decided that the Plan does not have to pre-approve a Crutch substitute
(E0118).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the core build up (procedure code D2950) prior to
getting a crown.
You asked the Plan to pre-approve the core buildup. You say that this is a medically necessary service needed
before you get a crown. You said that your tooth has a fractured filling that needs to be fixed before a crown
can be placed. The Plan denied your request. The Plan says this service is not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a
dental benefit in excess of Medicare coverage, 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 the core build up
(procedure code D2950) prior to getting a crown.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for to pay for procedure code 74177-26 billed for date of service
October 1, 2021. You asked the Plan to pay for procedure code 74177-26. You say that the patient had multiple exams on this
date of service. The Plan denied your request. The Plan says payment for this code is bundled into payment for
74174-26.
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
procedure code 74177-26 is a column II code to column I code 74174-26. 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 to pay for procedure code 74177-26
billed for date of service October 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve guided tissue regeneration - resorbable barrier, per site
(D4266) and bone replacement graft for ridge preservation - per site (D7953).
You asked the Plan to pre-approve guided tissue regeneration and bone replacement graft. You say that these
services are medically necessary. The Plan denied your request. The Plan says these services are not covered
under the enrollee's 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 pre-approve
guided tissue regeneration - resorbable barrier, per site (D4266) and bone replacement graft for ridge
preservation - per site (D7953)
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Droxidopa capsules.

You asked the Plan to pre-approve Droxidopa capsules. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says Droxidopa capsules are not covered under the enrollee's Medicare Part B benefit.

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 Droxidopa capsules.

Benefits for Droxidopa capsules 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that you currently require physical, occupational and
speech therapy to return to prior level of function. You say that this is a skilled need and you do not agree with
the denial. The Plan denied your request. The Plan says the care you need can safely be received at a different
setting. 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 nursing and therapy services are not necessary. Our physician reviewer found that services in the home
or an assisted living facility with home health services is more appropriate.
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 SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to a raised toilet seat you purchased on August 26, 2021.

You asked the Plan to a raised toilet seat. You say that you have asked for additional reimbursement for durable medical equipment purchased. You said that your neurologist provided supporting information for these items. The Plan denied your request. The Plan says it has made additional payment for the wheelchair, walker, and seat lift you purchased, so those items are not in dispute. The Plan says that the raised toilet seat is not a covered benefit.

The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered because they are not primarily medical in nature. While a raised toilet seat may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to a raised toilet seat you purchased on August 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic or diagnostic injection (62320) provided on
August 30, 2021.
You asked the Plan to pay for the injection. You say that you would like reconsideration based on the records
submitted. The Plan denied your request. The Plan says the documentation submitted does not support the
medical necessity of the service billed.
The Plan must follow Medicare rules. Medicare rules say that the procedural report should clearly document
the indications and medical necessity for the blocks along with the pre and post percent (%) pain relief
achieved immediately post-injection.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the injection have not been met. Specifically, the medical records submitted are not signed and do
not document the pre and post percent of pain relief achieved immediately post-injection. Therefore, we decided that the Plan does not have to pay for the therapeutic or diagnostic injection (62320)
provided on August 30, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services provided on June 17, 2021.
You asked the Plan to pay for the anesthesia services. You say that the Plan has denied this claim erroneously.
You said that the hospital billed only for the medicine that the anesthesiologist administered. You are
requesting payment for the anesthesiologist's services. The Plan denied your request. The Plan says this claim
is a duplicate of one already paid.
The Plan must follow Medicare rules. Medicare rules say that duplicate bills are not paid.
Records show that on this date of service, the anesthetist provided two services to the patient. One service was
25 minutes long, and one service was 206 minutes long. The Plan already paid for the 25 minute long service
to this provider on claim OEB 36485306-00. This payment was specifically for the provider's services, not for
the hospital's services. The service you are appealing is the same 25 minute long procedure. It does not appear
as though you have appealed for payment of the 206 minute long procedure. We looked at the file and
Medicare rules. Based on this information, we decided that Medicare rules for coverage of the anesthesia
services have not been met. Please note that if you wish to appeal for the 206 minute long procedure, you will
need to contact the Plan directly to start that process. Therefore, we decided that the Plan does not have to pay for anesthesia services provided on June 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 62320 billed for date of service September 6, 2021.
You asked the Plan to pay for procedure code 62320. You say that this code was billed appropriately. The Plan denied your request. The Plan says the unsigned medical record provided does not support billing of this code.
The Plan must follow Medicare rules. Medicare rules say that for codes billed for epidural steroid injections for pain management, the medical records must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient. In addition, the medical records must document the medical necessity for the blocks with the pre and post percent pain relief achieved immediately post-injections. We looked at the file and Medicare rules. The single medical record provided is not signed. In addition, the medical record does not document the pre and post injection percent pain relief. Based on this information, we decided that Medicare rules for coverage of procedure code 62320 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 62320 billed for date of service September 6, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 62320 billed for date of service October 4, 2021.
You asked the Plan to pay for procedure code 62320. You say that this code was billed appropriately. The Plan denied your request. The Plan says the unsigned medical record provided does not support billing of this code.
The Plan must follow Medicare rules. Medicare rules say that for codes billed for epidural steroid injections for pain management, the medical records must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient. In addition, the medical records must document the medical necessity for the blocks with the pre and post percent pain relief achieved immediately post-injections. We looked at the file and Medicare rules. The single medical record provided is not signed. In addition, the medical record does not document the pre and post injection percent pain relief. Based on this information, we decided that Medicare rules for coverage of procedure code 62320 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 62320 billed for date of service October 4, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services (99205 and 90838) provided on
September 27, 2021.
You asked the Plan to pay for the psychotherapy services. You say that you would like reconsideration because
the member should be reimbursed for these services. The Plan denied your request. The Plan says this provider
has opted out of Medicare.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary
for items or services provided directly by a physician or practitioner who has opted out of the program except
in cases involving emergencies or urgently needed care.
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the
psychotherapy services (99205 and 90838) provided on September 27, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.

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 enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for peripheral vascular disease and had an above the knee amputation. Medical problems are stable. There are no complex nursing or rehabilitation needs. 

The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, in an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the fluoride application (D1206) provided on September 23,
2021.
You asked the Plan to pay for the dental service. You say that this service is covered. The Plan denied your
request. The Plan says there is a $500 annual maximum benefit. The Plan also says that the maximum benefit
has 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.
Though the Plan offers a dental benefit in excess of Medicare coverage, the annual maximum benefit has been
exhausted. Date of Service Plan Paid
3/16/2021 $155
3/30/2021 $143
4/7/2021 $143
9/30/2021 $59
TOTAL: $500
Additionally, the Evidence of Coverage clearly states that after the annual maximum is exhausted, any
remaining charges are your responsibility. Therefore, we decided that the Plan does not have to pay for the
fluoride application (D1206) provided on September 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic or diagnostic injection (62320) provided on October 11, 2021.

You asked the Plan to pay for the therapeutic or diagnostic injection. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the service billed.

The Plan must follow Medicare rules. Medicare rules say that the patient's medical record should include documentation to support the medical necessity of the procedure(s). 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the therapeutic or diagnostic injection have not been met. Specifically, the medical records submitted are not signed for the date of service at issue. Additionally, there is insufficient information to determine if Medicare criteria for coverage have been met. Therefore, we decided that the Plan does not have to pay for the therapeutic or diagnostic injection (62320) provided on October 11, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vascepa.
You asked the Plan to pre-approve Vascepa. The Plan denied your request. The Plan says this is not a covered
benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Vascepa.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide additional routine transportation to doctor's office visits.
You asked the Plan to provide additional routine transportation. You say that you need this transportation and
you cannot afford to take a taxi. The Plan denied your request. The Plan says you have exhausted your
transportation benefit.
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 10 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 additional routine transportation to doctor's office visits
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic or diagnostic injection (62320) provided on
September 27, 2021.
You asked the Plan to pay for the therapeutic or diagnostic injection. You say that you would like
reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation
submitted does not support the medical necessity of the services billed.
The Plan must follow Medicare rules. Medicare rules say that to consider coverage and payment for any item
or service, 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 the therapeutic or diagnostic injection have not been met. Specifically, the documentation
submitted does not include any medical records. There is insufficient information to determine if Medicare
criteria for coverage have been met. Therefore, we decided that the Plan does not have to pay for the
therapeutic or diagnostic injection (62320) provided on September 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller with harness and electronic connection.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that an expandable controller and harness are approved to control multiple power options. We looked at the file and Medicare rules. The file shows that the requested expandable controller with harness and electronic connection is not needed to control the approved power switches. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller with harness and electronic connection.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic or diagnostic injection (62320) provided on July 26, 2021.

You asked the Plan to pay for the injection. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not meet Medicare criteria for coverage.

The Plan must follow Medicare rules. Medicare rules say that documentation must include a signed and dated office visit record/operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed.) 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the injection have not been met. Specifically, the documentation submitted is not signed and dated for the billed date of service. There is insufficient information to determine if Medicare criteria for coverage have been met. Therefore, we decided that the Plan does not have to pay for the therapeutic or diagnostic injection (62320) provided on July 26, 2021.