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

We decided that the Plan does not have to pre-approve a core buildup (D2950) to be provided by a participating provider.
You asked the Plan to pre-approve a core buildup. You say that you would like the Plan to pay for this. The Plan denied your request. The Plan says D2950 is denied when an amalgam restoration is requested as well.
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 a core buildup when the services are medically necessary and reasonable.
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a core buildup have not been met. Therefore, we decided that the Plan does not have to pre-approve a core buildup (D2950) to be provided by a participating provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0675).
You asked the Plan to pre-approve a pneumatic compression device. You say that the device is medically
necessary. The Plan denied your request. The Plan says this type of pneumatic compression device is not
covered. The record shows no evidence of lymphedema.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement.
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan.
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to
pre-approve a pneumatic compression device (E0675).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xiidra 5% drops.
You asked the Plan to pre-approve Xiidra. You say that this medication is medically necessary for the
enrollee's condition. The Plan denied your request. The Plan says this drug is not covered under the enrollee's
medical 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 Xiidra 5% drops.
Benefits for Xiidra 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete denture - maxillary (D5110).
You asked the Plan to pre-approve a complete upper denture. You say that this service is necessary for your health. The Plan denied your request. The Plan says this service is 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 pre-approve a complete denture - maxillary (D5110).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the interpretation of the computed tomography (CT) scan of
the head provided on June 19, 2021, billed with code 70450.
You asked the Plan to pay for the CT interpretation as billed. You say that the medical records support that
payment should be made. The Plan denied your request. The Plan says this service was not billed with the
required modifier.
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 70450
is a column II code to column I code 70496. 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 the interpretation of the computed tomography (CT) scan of the
head provided on June 19, 2021, billed with code 70450.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve six surgical placements of implant bodies: endosteal implants (D6010 x6).  You asked the Plan to pre-approve the endosteal implants. You say that you are unable to wear dentures, and not having teeth is affecting your health. The Plan denied your request. The Plan says this service is not covered under your benefit package.  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 six surgical placements of implant bodies: endosteal implants (D6010 x6).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a power scooter.  You asked the Plan to pre-approve a power scooter. You say that you need this scooter to go shopping and go on vacations with your family. The Plan denied your request. The Plan says the requested device is not a covered benefit for outside of the home.  The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home.   The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a power scooter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for inpatient care provided from September 29, 2020, to October 1, 2020, and billed with DRG (diagnosis related group) 177.  You asked the Plan to pay for inpatient care. You say that this was billed correctly. The Plan denied your request. The Plan says the billed DRG is not supported.  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 DRG 177, respiratory infections and inflammations with major complications or comorbidities. 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 care. Our reviewer says that the records do not support DRG 177. Our physician reviewer found the records do not include a culture or gram stain supporting a gram-negative pneumonia being present. There was no hypoxia noted requiring more than 4 liters of oxygen. A low body mass index or signs of muscle wasting were not documented. There was no record of the enrollee needing dialysis.   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 care provided from September 29, 2020, to October 1, 2020, and billed with DRG (diagnosis related group) 177.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve foot orthotics.  You asked the Plan to pre-approve foot orthotics. You say that you have nephropathy and ulcers on your feet. The Plan denied your request. The Plan says this item is not a covered benefit.  Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.    Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM).  You asked the Plan to pre-approve a therapeutic CGM. You say that this item is medically necessary for your condition. The Plan denied your request. The Plan says the criteria for coverage of the CGM have not been satisfied.  The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.  We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office consultation to be rendered by the out-of-
network (OON) provider.
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's
denial. The Plan denied your request. The Plan says there are in-network providers available to perform the
requested service.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the service at issue in this appeal. We found no exception that would require the
Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve an office
consultation to be rendered by the out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dupixent injections.
You asked the Plan to pre-approve Dupixent injections. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says Dupixent injections 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 Dupixent injections.
Benefits for Dupixent injections 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: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve inpatient psychiatric care from January 13, 2022, forward.  You asked the Plan to pre-approve inpatient psychiatric care from January 13, 2022, forward. You say that the services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are not medically necessary.  The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.   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 inpatient psychiatric care from January 13, 2022, forward. Our reviewer says that you do not meet the criteria for acute inpatient mental health treatment beyond the date in question of January 13, 2022, forward. Our physician reviewer found you did not require inpatient mental health treatment beyond January 13, 2022, as you were not a danger to yourself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve your condition or for the purpose of diagnosis.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric care from January 13, 2022, forward have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from January 13, 2022, forward.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a core buildup (D2950) and porcelain ceramic crown (D2740) for tooth #19.  You asked the Plan to pre-approve the core buildup and crown. You say that these services are medically necessary. The Plan denied your request. The Plan says the enrollee previously had these services performed and covered for this tooth in August of 2020. One crown may be covered per tooth every 60 months.  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 can cover one crown per tooth every five years.  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested crown services for tooth #19 are requested in a frequency that exceeds what is covered under this benefit. Documentation shows that the enrollee had a crown provided and covered for tooth #19 in August of 2020, which is less than five years before this request. Therefore, we decided that the Plan does not have to pre-approve a core buildup (D2950) and porcelain ceramic crown (D2740) for tooth #19.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1392).  You asked the Plan to pre-approve a portable oxygen concentrator. You say that this is medically necessary. The Plan denied your request. The Plan says there is no evidence that the current items do not meet your needs.  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 you have a home oxygen set up and portable tanks. These items serve the same purpose as a portable oxygen concentrator. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1392).
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the nasal/sinus endoscopy (31238) provided on January 12, 2021.  You asked the Plan to pay for the nasal/sinus endoscopy (31238). You say that the supporting documentation should be reviewed as the services have been deemed payable. The Plan denied your request. The Plan says the services are 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.  In this case, the CPT Code Manual definition of code 31238 is nasal/sinus endoscopy, surgical; with control of nasal hemorrhage.    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 nasal/sinus endoscopy (31238). Our reviewer says that this does not meet the criteria for billing or reimbursement consideration. Our reviewer found that the medical records provided do not include sufficient documentation to validate that a nasal/sinus endoscopy, surgical; with control of nasal hemorrhage was performed on January 12, 2021, therefore this service cannot be verified.  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 nasal/sinus endoscopy (31238) have not been met. Therefore, we decided that the Plan does not have to pay for the nasal/sinus endoscopy (31238) provided on January 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a heavy-duty rollator walker.  You asked the Plan to pre-approve heavy duty rollator walker. You say that a standard walker does not meet your needs and is not sturdy enough for use. The Plan denied your request. The Plan says the denial of authorization for this item is correct, because you weigh less than 300 pounds so do not meet criteria for a heavy-duty walker.  The Plan must follow Medicare rules. Medicare rules say that a heavy-duty walker is covered for beneficiaries who meet criteria for a standard walker and weigh more than 300 pounds.   We looked at the file and Medicare rules. The record shows that you do not weigh more than 300 pounds. Based on this information, we decided that Medicare rules for coverage of heavy-duty rollator walker have not been met. Therefore, we decided that the Plan does not have to pre-approve a heavy-duty rollator walker.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) therapy rendered on August 4, 2021.  You asked the Plan to pay for 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. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home.   The file shows that the equipment was used outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) therapy rendered on August 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the comprehensive oral exam (D0150) provided on October 11, 2021.  You asked the Plan to pay for the comprehensive exam. You say that this was just a regular cleaning, and the Plan should pay for these services in full. The Plan denied your request. The Plan says your dental benefit covers one comprehensive oral exam every 36 months. You previously had this service in February of 2020, and the exam was covered and paid for at that time. It has not been 36 months since your last comprehensive exam; therefore, this service is denied.  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's dental benefit can cover one comprehensive oral exam every 36 months.  Though the Plan offers a dental benefit in excess of Medicare coverage, the comprehensive exam is requested in a frequency that exceeds what is covered by this benefit. Documentation supports that you had a previous comprehensive exam less than 36 months before the date in question, which was covered at that time. Therefore, we decided that the Plan does not have to pay for the comprehensive oral exam (D0150) provided on October 11, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

 We decided that the Plan has to pre-approve a home mechanical (portable) 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 that the request for a home mechanical ventilator set in intelligent volume assured pressure support (iVAPS) mode that could be delivered by bilevel positive airway pressure (BiPAP) is not covered.  The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.  The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Case Narrative appears to indicate that the plan had medical records available for their review and denial. There were no medical records provided for review to MAXIMUS. Therefore, we decided that the Plan has to pre-approve a home mechanical (portable) ventilator.   If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office visits (99203) to be provided by an out-of-
network (OON) provider.
You asked the Plan to pre-approve office visits. You say that you have had bad experiences with two in-
network providers. The Plan denied your request. The Plan says there are additional in-network providers
available.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
office visits (99203) to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve endodontic therapy, anterior tooth (excluding final restoration) (D3310).  You asked the Plan to pre-approve a root canal. You say that the enrollee needs this service. The Plan denied your request. The Plan says this service is 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 pre-approve endodontic therapy, anterior tooth (excluding final restoration) (D3310).