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

We decided that the Plan does not have to pay for the three pontics (D6240 x3), three retainer crowns (D6750
x3), and one core buildup, including any pins when required (D2950), or pay more for the two additional core
buildups provided on March 16, 2021.

You asked the Plan to pay for the pontics, retainer crowns, and one core buildup, and to pay more for the two
additional core buildups.

You say that your dentist advised that the bridges would be covered in full by the Plan. The Plan denied your
request. The Plan says pontic and retainer crown are not covered services. The Plan also says that the core
buildup exceeds the benefit allowance.

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 pontic (D6240) and retainer crown
(D6750) are not among those covered under this benefit. The contract says that core buildup, including any
pins when required (D2950) is limited to two of either codes D2950, D2952, or D2954 per calendar year. You
are also responsible for a $20.00 copayment for each covered core buildup. The record shows that you received
three core buildups, including any pins when required (D2950 x3) on March 16, 2021, two of which were
covered by the Plan and you must pay the $20.00 copayment for each of these, and your core buildup,
including any pins when required (D2950) benefit has been exhausted. Therefore, we decided that the Plan
does not have to pay for the three pontics (D6240 x3), three retainer crowns (D6750 x3), and one core buildup,
including any pins when required (D2950), or pay more for the two additional core buildups provided on
March 16, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Orgovyx 120mg tablet.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your
request. The Plan says this is a self-administered drug.

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 Orgovyx 120mg tablet.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 8 additional chiropractic visits.

You asked the Plan to pre-approve the additional chiropractic visits. You say that the additional visits are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance care. 

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 additional chiropractic visits. Our reviewer says that the additional visits are not medically necessary. Our physician reviewer found when further clinical improvement cannot be reasonably expected from ongoing care, the care is considered maintenance. The record indicates that the enrollee has been receiving treatment with no significant changes in assessment. The record does not indicate that further clinical improvement can be reasonably expected. 

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 additional chiropractic visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 8 additional chiropractic visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed.

You asked the Plan to pre-approve a semi-electric hospital bed. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee already has a hospital bed.

The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. 

The file shows that the enrollee previously received a semi-electric hospital bed in 2018. Therefore, we decided that the Plan does not have to pre-approve a semi-electric hospital bed.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a varicose vein ablation procedure (36475).
You asked the Plan to pre-approve the procedure. You say that the procedure is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that this procedure is covered when medically necessary. 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 procedure is not medically necessary. Our physician reviewer found the record indicates that the enrollee has a 1.5 cm aneurysm in the target segment of the vein. The elements of the coverage criteria are not satisfied, and this 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 the procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a varicose vein ablation procedure (36475).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the onabotulinumtoxina injection (CPT code J0585), for
the enrollee.
You asked the Plan to pre-approve the injection. You say that you are requesting review of denial of services.
The Plan denied your request. The Plan says the enrollee's doctor did not send notes that show how many
headaches the enrollee has each week and month. The Plan states that they do not know if this medicine will
help the enrollee; therefore, this medicine (botulinum toxin type, per unit) is not medically necessary.
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 injection. Our physician reviewer
found the records submitted do not provide information on the enrollee's baseline headaches. The clinical
documentation provided was a procedure note from a follow-up visit. There was no clinical documentation
provided that show how many headaches the enrollee has each week/ month. The review has determined that
the medical records provided do not meet the requirements listed in the LCD for Medicare coverage. 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 injection have not been met. Therefore, we decided that the Plan does not
have to pre-approve the onabotulinumtoxina injection (CPT code J0585), for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established
patient (D0150), prophylaxis - adult (D1110), bitewings - four radiographic images (D0274), topical
application of fluoride varnish (D1206), and panoramic radiographic image (D0330) provided April 29, 2021.
You asked the Plan to pay for the comprehensive oral exam, dental cleaning, bitewing x-rays, fluoride varnish
and panoramic x-ray. You say that you were told you were covered. The previous dentist retired, and you
requested the new dentist call the Plan and request to join the Plan's network. The Plan denied your request. The Plan says that there is no record that you were referred to the dental office by the Plan. The services were
not rendered by a participating provider and therefore 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. The Plan covers the
comprehensive oral exam, dental cleaning, bitewing x-rays, fluoride varnish and panoramic x-ray when the
services are provided by a network provider.
We looked at the file and Medicare rules. The Plan had network providers available who could provide the
items/services at issue in this appeal. We found no exception that would require the Plan to pay for the dental
services at issue. Based on this information, we decided that the Plan's rules for coverage of the comprehensive
oral exam, dental cleaning, bitewing x-rays, fluoride varnish and panoramic x-ray have not been met.
Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation - new or
established patient (D0150), prophylaxis - adult (D1110), bitewings - four radiographic images (D0274),
topical application of fluoride varnish (D1206), and panoramic radiographic image (D0330) provided April 29,
2021.
Your complaint about potentially receiving misinformation about network providers and the different network
statuses of providers in the same office is not a valid appeal for medical coverage. This part of your complaint
is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these
types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.
You asked the Plan to pre-approve incontinence supplies. You say that the supplies are necessary. The Plan
denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered
because they are hygienic items that are non-reusable.
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the thyroid stimulating hormone (84443) provided on March 24, 2021.

You asked the Plan to pay for the thyroid stimulating hormone. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this code has been previously processed and paid.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The rules also say that duplicate claims will not be paid. 

We find that CPT code 84443 is not supported in the record. Specifically, the records indicate that this service was previously processed and paid to the same provider for the same date of service. Additionally, the file does not include any clinical information to validate the service at issue or determine if this service was rendered more than once. Based on this information, we decided that Medicare rules for coverage of the thyroid stimulating hormone have not been met. Therefore, we decided that the Plan does not have to pay for the thyroid stimulating hormone (84443) provided on March 24, 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 IRF admission is medically necessary. The Plan
denied your request. The Plan says the enrollee's needs can be met at a different level of care.
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 based on the medical records provided the complexity of the enrollee's nursing,
medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary
approach to rehabilitation care.
It is not clear the enrollee would be able to fully benefit and/or participate in an IRF level of care.
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 unspecified preventative procedure, by report (D1999),
resin-based composite - two surfaces, posterior (D2392), resin-based composite - three surfaces, posterior
(D2393), analgesia, anxiolysis, inhalation of nitrous oxide (D9230), resin-based composite - one surface,
posterior (D2391), crown - porcelain/ceramic (D2740), and core buildup, including any pins when required
(D2950) provided April 26, 2021, and April 29, 2021.

You asked the Plan to pay for the unspecified preventative procedure, resin-based composites, analgesia, crown
and core buildup. You say that the dental services were medically necessary. The Plan denied your request. The
Plan says these services are not covered under your benefits.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
unspecified preventative procedure, by report (D1999), resin-based composite - two surfaces, posterior
(D2392), resin-based composite - three surfaces, posterior (D2393), analgesia, anxiolysis, inhalation of nitrous
oxide (D9230), resin-based composite - one surface, posterior (D2391), crown - porcelain/ceramic (D2740),
and core buildup, including any pins when required (D2950) provided April 26, 2021, and April 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mobility scooter.

You asked the Plan to pre-approve a mobility scooter. You say that you feel that this item is medically necessary. The Plan denied your request. The Plan says you do not meet criteria for the requested item.

The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 

The file shows that you do not have a mobility deficit that impairs your participation in MRADLs and your condition can be improved by a walker, cane or manual wheelchair. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a mobility scooter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care provided to the enrollee from June 29, 2020, through July 3, 2020.

You asked the Plan to pay for inpatient hospital care. You say that the diagnosis is supported. The Plan denied your request. The Plan says they have confirmed that one or more of the billed diagnosis were not supported by the clinical records and/or did not impact the clinical resource utilization. The Plan states that it remains excluded when determining their derived diagnosis-related group (DRG)

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services provided with Sepsis A41.9. 

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 inpatient hospital care. Our physician reviewer found the review has determined that the clinical documentation does not support the diagnosis of Sepsis A41.9. The records support significant pulmonary infection without evidence for sepsis. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient hospital care provided to the enrollee from June 29, 2020, through July 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve consultation with a pain management specialist at a tertiary-level provider.

You asked the Plan to pre-approve the tertiary-level pain management consultation. You say that you do not wish to see any other provider than the specialists at the requested facility. The Plan denied your request. The Plan says there is nothing in the record that suggests that your needs cannot be met by the approved pain management specialist.

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 tertiary-level pain management consultation. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is a male with morbid obesity and chronic back pain. He has been prescribed a non-steroidal anti-inflammatory drug (NSAID) and tramadol for pain. There is no documentation of a rare or complex pain problem that could not be managed by the network pain specialist offered by the Plan. There is no documented need to have treatment provided from a tertiary academic medical center.

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 tertiary-level pain management consultation have not been met. Therefore, we decided that the Plan does not have to pre-approve consultation with a pain management specialist at a tertiary-level provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous spacer placement procedure (22869).

You asked the Plan to pre-approve the interspinous spacer placement procedure. You say that the spacer placement is medically necessary. The Plan denied your request. The Plan says this procedure is investigational and is not covered.

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 interspinous spacer placement procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has chronic low back pain and lumbar spinal stenosis with neurogenic claudication. The record indicates that imaging has not demonstrated moderate spinal stenosis at L4-L5, the level requested for treatment. The record does not indicate that the pain is relieved in flexion. This procedure is not medically necessary based on the records.

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 interspinous spacer placement procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous spacer placement procedure (22869).
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to reimburse you more for the prosthetic eye you purchased on April 16, 2021.

You asked the Plan to reimburse you more for the prosthetic eye. You say that you paid $3500 out-of-pocket for the ocular prosthesis but were only reimbursed $773.48. You would like additional reimbursement made on this claim. The Plan denied your request. The Plan says that you were reimbursed correctly. The Plan says that the Medicare-allowed amount for the ocular prosthesis you received is $966.85, so you were reimbursed the correct amount when your 20% coinsurance was deducted.

The Plan must follow Medicare rules. Medicare rules say that when you use a non-contracted, non-Medicare participating durable medical equipment (DME) provider, the Plan is required to pay the difference between the enrollee's cost sharing and the DME supplier's bill. This cost is NOT based on the Medicare-allowed rate. In this case, we know that the provider from whom you received the ocular prosthesis is a non-contracted provider. There was no evidence in the file provided by the Plan to indicate if this provider participates in Medicare or not. We sent a request for information to the Plan to determine this provider's Medicare status. The Plan failed to respond to that request. Based on limited information available online, it appears as though the provider you used does not accept Medicare. Using this assumption, the Plan is obligated to pay the difference between your 20% coinsurance and the provider's bill. In this case, the provider's bill was $3500. When your 20% coinsurance ($700) is subtracted, that would mean that the Plan is obligated to reimburse you the difference of $2800. To date, the Plan has only reimbursed you $773.48. That means that the Plan must issue additional payment to you in the amount of $2026.52. Therefore, we decided that the Plan has to reimburse you more for the prosthetic eye you purchased on April 16, 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6530.

You asked the Plan to pre-approve the compression stockings. You say that you require the stockings for venous insufficiency. The Plan denied your request. The Plan says are noncovered because they do not meet the statutory definition of a dressing.

The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are noncovered because they do not meet the statutory definition of a surgical dressing. 

Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan.

Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6530.