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

We decided that the Plan does not have to pay for the fluoride varnish application provided on June 30, 2021.
You asked the Plan to pay for the fluoride varnish application. You say that its preventive care and should be
covered. The Plan denied your request. The Plan says the service is not a covered benefit.
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
fluoride varnish application provided on June 30, 2021
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (97110) provided on May 12, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not supported.

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 services. Our reviewer says that the use of code 97110 is not supported by the records provided. Our reviewer found that the medical records document that this service was performed in a home health or hospice setting. Code 97110 is not the most appropriate code to represent the service performed. There is a more appropriate Healthcare Common Procedure Coding System code to use to bill this service.

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services (97110) provided on May 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the implant removal and bone replacement graft provided on March 12, 2021.
You asked the Plan to pay for the implant removal and bone replacement graft. You say that the dentist advised that teeth extraction needed to be done immediately. You say that this was accidentally processed as a dental procedure and you are looking for a full refund. The Plan denied your request. The Plan says the limited oral evaluation will be covered, and the implant removal and bone replacement graft remain denied as non-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 implant removal and bone replacement graft provided on March 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the frames and lenses purchased on May 4, 2021.
You asked the Plan to pay more for the frames and lenses. You say that you have not utilized any optical frame
benefits and you cannot understand how the claim could be denied. The Plan denied your request. The Plan
says the optical frame allowance has been exhausted.
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 $150 every 24 months for eyewear.
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for
coverage of the frames and lenses have not been met. Specifically, the Plan paid $150 toward the cost of the
frames and lenses and you are responsible for the additional cost. Therefore, we decided that the Plan does not
have to pay more for the frames and lenses purchased on May 4, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for a colonoscopy (45385) provided February 19, 2021.
You asked the Plan to pay for the colonoscopy. You say that the services were medically necessary. The Plan
denied your request. The Plan says the documentation does not support the billed services.
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 45385 is not supported in the medical record. Specifically, the medical records provided
do not include sufficient documentation to validate that a Colonoscopy, flexible; with removal of tumor(s),
polyp(s), or other lesion(s) by snare technique was performed. Based on this information, we decided that
Medicare rules for coverage of the colonoscopy have not been met. Therefore, we decided that the Plan does
not have to pay for a colonoscopy (45385) provided February 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the air conditioner purchased June 14, 2021.
You asked the Plan to pay for the air conditioner. You say that you believe Plan had a rebate if you purchased an air conditioner. The Plan denied your request. The Plan says neither the Plan nor Medicare covers this equipment.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. In addition, the rebate that you saw was only for members enrolled in the Respiratory Care Management program. We have confirmed you are not a part of this program. Therefore, we decided that the Plan does not have to pay for the air conditioner purchased June 14, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services (A0429) provided December 13, 2020.
You asked the Plan to pay for the ambulance services. You say that the services were medically necessary. The Plan denied your request. The Plan says the billed code is not supported in the records.
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 A0429 is not supported in the medical record. Specifically, the record shows the patient was pronounced deceased after the ambulance was called. In this case providers must bill code A0428 with the QL modifier. Based on this information, we decided that Medicare rules for coverage of the ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for ambulance services (A0429) provided December 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a third vertebral level of facet joint injection.
You asked the Plan to pre-approve the facet joint injection at a third level. You say that it is felt that this should be approved to confirm the diagnosis of facet joint syndrome, and to allow for progression to facet joint denervation. The Plan denied your request. The Plan says two levels have been approved for diagnostic injection. More than two levels are only covered in unique circumstances which are not present in this case.
The Plan follows Medicare rules. Medicare rules say that facet joint injections are covered at one to two spinal levels. Additional levels are only covered in unique circumstances and with sufficient documentation of medical necessity. 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 facet joint injection at a third level.
Our reviewer says that the requested third level of injection of the facet joints is not considered medically necessary. Our physician reviewer found there is no documentation submitted with the appeal that demonstrated any unique circumstances that the member meets medical necessity to allow three levels to be done in one session. The review has determined that the service at issue in this case is not medically reasonable or 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 facet joint injection at a third level have not been met. Therefore, we decided that the Plan does not have to pre-approve a third vertebral level of facet joint injection
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided from
February 13, 2020, through February 28, 2020.

You asked the Plan to pay for SNF services. You say that the SNF services were medically necessary. The Plan
denied your request. The Plan says the SNF services were not medically necessary.

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 pay for SNF services. Our reviewer says that daily
skilled services were not medically necessary. Our physician reviewer found that from a nursing perspective,
the enrollee received oral medications. The enrollee had stable vital signs. Her appetite was fair. She was
treated for a urinary tract infection (UTI). Regarding rehabilitation services, the enrollee received physical
therapy (PT) and occupational therapy (OT). By the dates in question, the enrollee was at a modified
independent level with functional mobility including gait to 300 feet with a rolling walker. The enrollee
required varying assist with activities of daily living. There were no identifiable skilled nursing service needs.
There were no identifiable skilled therapy service needs. The enrollee did not require skilled nursing or therapy
services on a daily basis. As a practical matter, the enrollee did not meet severity of illness or intensity of
service criteria for an inpatient basis in a skilled nursing facility 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 pay for SNF services provided from February 13, 2020, through February 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and general anesthesia 
(D9222 and D9223) provided by an out-of-network provider on June 24, 2021. 
 
You asked the Plan to pay for a limited oral evaluation and general anesthesia. You say that you do not agree 
with this being denied because the provider is out-of-network. You say that you needed these services done. 
The Plan denied your request. The Plan says the dental services that were provided are not a covered benefit. 
 
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. The Plan has agreed to process these dental services as in-network due 
to lack of in-network providers available within a 30-mile radius.  
The dental services that were provided are not a covered benefit. Therefore, we decided that the Plan does not 
have to pay for a limited oral evaluation (D0140) and general anesthesia (D9222 and D9223) provided by an 
out-of-network provider on June 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Trilogy home ventilator for the enrollee.
You asked the Plan to pre-approve the ventilator. You say that any change to any other respiratory device
would harm the enrollee's health. The Plan denied your request. The Plan says a bilevel positive airway
pressure (BiPAP) device can provide the same support for home use and has been approved.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory
failure due to COPD.
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 ventilator. Our reviewer says that
the requested ventilator is not medically reasonable or necessary. Our physician reviewer found the enrollee
has chronic obstructive pulmonary disease, obstructive sleep apnea, and morbid obesity. The medical record
does not include any documentation of carbon dioxide retention. Certain BiPAP devices can provide the
AVAPS mode of support, and Medicare does not cover a home ventilator when used as BiPAP.
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 ventilator have not been met. Therefore, we decided that the Plan does not
have to pre-approve a Trilogy home ventilator for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the fluoride varnish application, nutritional counseling and 
oral hygiene instructions provided on June 24, 2021. 
 
You asked the Plan to pay for the fluoride varnish application, nutritional counseling and oral hygiene 
instructions. You say that while the procedures appear insignificant by themselves, they are in support of your 
periodontal disease. You say that you believe in preventive care instead of more extensive actions as a result. 
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 
fluoride varnish application, nutritional counseling and oral hygiene instructions provided on June 24, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says the studies do not demonstrate equal or superior benefits or advantages over commercially available alternatives or fusion surgery.
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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the device is experimental. More research is needed to show safety and efficacy.
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 device have not been met. Therefore, we decided that the Plan does not have
to pre-approve the Vertiflex device for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the removal of residual tooth roots (D7250) for tooth # 12, 
therapeutic parenteral drugs (D9612), initial 15 minutes of conscious sedation (D9239), and additional 15 
minutes of conscious sedation (D9243) provided on June 15, 2021. 
 
You asked the Plan to pay for the removal of residual tooth roots for tooth # 12, therapeutic parenteral drug, 
and sedation. You say that your provider was advised that you were covered and to proceed with the treatment. 
You say that you were advised your portion of the bill would be $848. You say you received a bill for $1,577. 
You say that you could not afford to have the teeth pulled without insurance. You also say that you are on a 
fixed income and could use some help. The Plan denied your request. The Plan says 2 oral surgery procedures 
per calendar year with a 70% coinsurance when received in network. The Plan says that the frequency limit for 
this service has been exceeded. 

The Plan says therapeutic parenteral drug is not listed as a covered service. 
The Plan says that sedation services are not listed as covered services either. The Plan also says that the services in 
this case paid as a one-time exception as the provider does not participate with Medicare. 
 
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 oral surgery services are listed as 
covered, the frequency limit has been exceeded. The record shows that the Plan paid the in-network rate for the 
removal of residual tooth roots for teeth #s 8 and 11. The 70% coinsurance still applies. Additionally, the 
therapeutic parenteral drug and sedation services are not among those covered under this benefit. Therefore, we 
decided that the Plan does not have to pay for the removal of residual tooth roots (D7250) for tooth # 12, 
therapeutic parenteral drugs (D9612), initial 15 minutes of conscious sedation (D9239), and additional 15 
minutes of conscious sedation (D9243) provided on June 15, 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 enrollee will clearly benefit from IRF to optimize 
his level of function prior to returning home. The Plan denied your request. The Plan says the denial of 
authorization for IRF service is correct. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found 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. While the 
enrollee may need physical and/or occupational therapy, there is no documented need for an intensive 
rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully participate in 
- and benefit from - the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electronic connection between 2 systems.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the enrollee is able to control power options using their own switches.
The Plan follows Medicare rules. Medicare rules say that wheelchair options and accessories are only covered under certain medical indications. 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 there is no documentation that the enrollee is unable to control the approved power options through their own switches. The records indicate the enrollee is independent with self-feeding. The wheelchair is reportedly set up for left-handed controls. The records do not indicate any limitations, contractures, fisting, tremors, weak grasp, poor dexterity, non-functional hand movement or paralysis of the left hand. Based on the medical records, there is no documentation that the requested control system meets Medicare criteria for reasonable or necessary for the power wheelchair. 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 does not have to pre-approve an electronic connection between 2 systems.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetics interpretation and report provided on May 10, 
2021. 
 
You asked the Plan to pay for the services provided. You say that medical records show the enrollee's critical 
condition at the time of services. The Plan denied your request. The Plan says the service cannot be separately 
reimbursed. 
 
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 88291 is cytogenetics and molecular cytogenetics, 
interpretation and report. We looked at the file and the rules. We find that code 88291 may be eligible for 
payment with an appropriate modifier. However, modifiers shall not be used to bypass a PTP edit unless the 
proper criteria for use of the modifier are met. Based on this information, we decided that Medicare rules for 
coverage of services billed with a -XU modifier have not been met. Therefore, we decided that the Plan does 
not have to pay for the genetics interpretation and report provided on May 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis and periodic oral evaluation provided on July 7, 2021.
You asked the Plan to pay for the prophylaxis and periodic oral evaluation. You say that you have very limited funds, and the decision should be reconsidered. The Plan denied your request. The Plan says services performed by an out-of-network provider are 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, out-of-network dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the prophylaxis and periodic oral evaluation provided on July 7, 2021.