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

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), and to pay more for the first intraoral periapical x-ray (D0220), and surgical extraction (D7210) provided on April 20, 2021, and May 4, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the problem focused limited oral evaluation, or pay more for the first intraoral periapical x-ray, and surgical extraction. You say that you were not aware that this treating provider was OON. The Plan denied your request. The Plan says the problem focused limited oral evaluation is not a covered benefit. The Plan also says that you are responsible for any difference between the Maximum Allowable Fee and the amount the provider bills you for the services, because these services were received OON.
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, problem focused limited oral evaluation (D0140) is not among those covered under this benefit. The contract says that you are responsible for a 50% coinsurance for intraoral x-rays, and a 55% coinsurance for extractions, plus the difference between the billed amount and allowed amount for covered dental services received OON. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), and to pay more for the first intraoral periapical x-ray (D0220), and surgical extraction (D7210) provided on April 20, 2021, and May 4, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a hereditary cardiovascular screening panel (81401) provided on March 12, 2021.
You asked the Plan to pay for a hereditary cardiovascular screening panel. You say that this was medically necessary. The Plan denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular (CV) risk assessment panels, except the basic lipid panel, for symptomatic and asymptomatic patients. We looked at the file and Medicare rules. The services at issue are a CV risk assessment panel and are not covered. Based on this information, we decided that Medicare rules for coverage of a hereditary cardiovascular screening panel have not been met. Therefore, we decided that the Plan does not have to pay for a hereditary cardiovascular screening panel (81401) provided on March 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an auricular electrical device.
You asked the Plan to pre-approve the requested services. You say that the enrollee is likely to obtain significant therapeutic benefit from the neurostimulator treatment. The Plan denied your request. The Plan says the service is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.
The file shows that a DyAnsys auricular electrical device was requested. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician reviewer found that the enrollee has chronic low back pain. She has tried physical therapy, a home exercise program, heat/ice, non-steroidal anti-inflammatory drugs (NSAIDs) and opiates. The requested device is considered experimental/ investigational. Therefore, it is deemed 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve an auricular electrical device
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete interim mandibular denture (D5811), adjunctive procedure (D1999), alveoloplasties in conjunction with extractions (D7311), endosteal implants (D6010), surgical extractions (D7210), bone replacement grafts for ridge preservation (D7953), and frenuloplasties (D7963) provided on April 26, 2021, and May 3, 2021 by a Medicare opt out provider.
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says you received these services from a provider who chose not to receive Medicare funds. The treating provider opted out of Medicare effective November 4, 2015, to November 4, 2021.
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 covered when they are received by a Medicare opt out provider. Therefore, we decided that the Plan does not have to pay for the complete interim mandibular denture (D5811), adjunctive procedure (D1999), alveoloplasties in conjunction with extractions (D7311), endosteal implants (D6010), surgical extractions (D7210), bone replacement grafts for ridge preservation (D7953), and frenuloplasties (D7963) provided on April 26, 2021, and May 3, 2021 by a Medicare opt out provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gemtesa tablet 75mg for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your
request. The Plan says there are no Medicare Part D benefits with this plan.
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 Gemtesa tablet 75mg for
the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 8 additional physical therapy visits.
You asked the Plan to pre-approve 8 additional physical therapy visits. You say that a medication your doctor prescribed was making you have seizures and fall. You say that therapy was denied but it should not have been. The Plan denied your request. The Plan says additional visits are not medically necessary.
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 pre-approve 8 additional physical therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that you had prior extensive therapy and have been approved 2 additional sessions that can be used to review a home exercise program. Our reviewer says that the unique skills of a professional therapist are not required to safely and effectively provide ongoing treatment. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 8 additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 8 additional physical therapy visits.
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 these services are medically necessary. The Plan 
denied your request. The Plan says that the continuation of skilled services can be provided on an intermittent 
basis on an outpatient basis, in a long-term care facility, or at the home with home health care services. 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 that your condition does not meet 
Medicare criteria for SNF services. 
 
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a non-invasive home ventilator.
You asked the Plan to pre-approve the ventilator. You say that this is medically necessary. The Plan denied your request. The Plan says the request cannot be 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 you have diagnoses of COPD and obesity hypoventilation syndrome, and were prescribed the ventilator following a hospitalization in August2020 for acute hypercarbic respiratory failure with mental status changes. More recent notes describe you as doing well on bilevel positive airway pressure (BiPAP), but presumably you have been using the ventilator rather than BiPAP. There is no documentation of COPD with pulmonary function tests, and
no documentation of carbon dioxide (C02) retention on an arterial blood gases (ABG) test. BiPAP has not been tried at home. BiPAP is the most appropriate treatment for you. Certain BiPAP device can provide the average volume-assured pressure support (AVAPS) mode of support. Medicare does not cover a 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 non-invasive home ventilator.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the nervous system surgery (64999) provided on January 20, 2021.

You asked the Plan to pay for the nervous system surgery. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the billed procedure code 64999 does not appear on Addendum AA for covered surgical procedures including surgical procedures for which payment is packaged and is found under the Addendum EE Surgical Procedures Finalized to be Excluded from Payment.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The rules also say that the Ambulatory Surgical Center (ASC) list of covered procedures merely indicates procedures which are covered and paid for if performed in the ASC setting. 

We find that CPT code 64999 is not supported in the record. Specifically, the record indicates that these services were provided in an ambulatory surgical center. CPT code 64999 does not appear as a covered surgical procedure or exemption on the the ASC Addendum AA or Addendum EE Based on this information, we decided that Medicare rules for coverage of the nervous system surgery have not been met. Therefore, we decided that the Plan does not have to pay for the nervous system surgery (64999) provided on January 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal scaling and root planing.
You asked the Plan to pre-approve periodontal scaling and root planing. You say that they are trying to save your tooth and you were advised you needed this service. The Plan denied your request. The Plan says periodontal scaling and root planing is not medically necessary.
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 periodontal scaling and root planing when the services are medically necessary and reasonable. 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 periodontal scaling and root planing. Our physician reviewer found that you have severe periodontal disease as noted by the extreme bone loss and pathologic periodontal pocketing. Our reviewer says that periodontal scaling and root planing would not be sufficient in treating your periodontal disease due to its severity.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of periodontal scaling and root planing have not been met. Therefore, we decided that the Plan does not have to pre-approve periodontal scaling and root planing.
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 these services are medically necessary. The Plan denied your request. The Plan says that you are receiving and benefiting from adequate and necessary intensive rehabilitation in the Inpatient Rehabilitation Facility.
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 that your condition does not meet Medicare criteria for SNF services. 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the two home-health occupational therapy visits.
You asked the Plan to pre-approve the two home-health occupational therapy visits. You say that the service is
medically necessary. The Plan denied your request. The Plan says the medical records do not support necessity
of the service as defined by Medicare criteria as no order was received for maintenance occupational therapy
treatment.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.
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 two-home health occupational
therapy visits. Our reviewer says that the service is not medically necessary. Our physician reviewer found the
available medical records do not include an order from the enrollee's treating provider for maintenance
occupational therapy services.
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 two home-health occupational therapy visits have not been met. Therefore,
we decided that the Plan does not have to pre-approve the two home-health occupational therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a vitrectomy support chair purchased March 15, 2021.
You asked the Plan to pay for this equipment. You say that this equipment was medically necessary for your use. The Plan denied your request. The Plan says the provider you purchased the equipment from is not a Medicare eligible provider.
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. The providers website specifically states that they do not accept Medicare insurance structures and that the equipment itself is not covered by Medicare. While it is understood this equipment may be beneficial for your use, this purchase was not authorized by the Plan, and the provider is not a Medicare eligible provider. Therefore, we decided that the Plan does not have to pay for a vitrectomy support chair purchased March 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physician's services for vision care provided on June 24, 2021.

You asked the Plan to waive the copayment for physician's services for vision care. The Plan denied your request. The Plan says the correct copayment was applied to the claim.

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 vision care, Medicare covered vision services. 

You have been asked to pay a $40 copayment for physician's services for vision care. Physician's services for vision care falls within the vision care, Medicare covered vision services 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 physician's services for vision care provided on June 24, 2021.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve home health physical therapy services. 
 
You asked the Plan to pre-approve home health services. The Plan denied your request. The Plan says the 
records do not support the need for a skilled therapist to make more home visits. The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our physician 
reviewer found that you have been learning how to walk and transfer safely, improve balance and learning 
exercises for endurance. You have had at least 13 visits for therapy and were taught a home exercise program. 
The documentation indicates you are able to ambulate and transfer safely in the home. In this case, the 
documentation does not support that you require additional skilled rehabilitation services to improve your 
condition, or to perform a maintenance program to maintain your condition or prevent deterioration. Therefore, 
the requested home health services are 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health physical therapy services.
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 services are medically necessary. The
Plan denied your request. The Plan says Medicare coverage criteria are not met.
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 complexity
of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an
interdisciplinary approach to rehabilitation care.
You were admitted for respiratory failure and COVID-19 pneumonia. Medical problems are now stable. There
are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including
either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is no
documented need for an intensive, multi-disciplinary rehabilitation program. Finally, there is not a reasonable
expectation that you 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 a bath/shower chair. 
 
You asked the Plan to pre-approve the chair. You say that this is medically necessary to help with qualify of 
life. The Plan denied your request. The Plan says this is not a covered benefit as it is a convenience item. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair 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 pre-approve a bath/shower chair.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (23430) provided on March 29, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled service.
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 23430 has a bundled relationship with code 23472 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the services (23430) provided on March 29, 2021.