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

We decided that the Plan does not have to pay for the consultation provided on May 4, 2021.

You asked the Plan to pay for the consultation. You say that you have extreme discomfort with the joint
ligaments on the left side of your head and this should be classified as medical. You say that you should be
reimbursed the $132 the Plan refused to pay. 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, a consultation with a dentist is not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
consultation provided on May 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and periapical x-ray (D0220) provided on May 18, 2021.

You asked the Plan to pay for the dental services. You say that your tooth broke in half. You say that it was very painful. You say that you had to have an x-ray to check for an infection so you could have your teeth pulled. You also say that your insurance should cover these services. The Plan denied your request. The Plan says limited oral evaluation is not listed as a covered service. The Plan says that the periapical x-ray is not listed as a covered service either.

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 limited oral evaluation and periapical x-ray are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) and periapical x-ray (D0220) provided on May 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the power wheelchair. You say that the claim should be approved. The Plan denied your request. The Plan says there are in network alternatives 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 a power wheelchair to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to preapprove an acute inpatient hospital admission.

You asked the Plan to preapprove acute inpatient hospital care. You say that preapproval for the inpatient admission is necessary. The Plan denied your request. The Plan says the enrollee is not expected to stay 2 midnights.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 

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 preapprove acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee is a generally healthy woman for whom total knee arthroplasty is planned. The documentation does not support that it is reasonable for the admitting physician to expect that the enrollee's necessary hospital care will span two midnights. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to preapprove an acute inpatient hospital admission.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869), for the enrollee.
You asked the Plan to pre-approve the surgery. You say that this is to treat the enrollee's lumbar spinal stenosis with neurogenic claudication because they have suffered from this condition too long and it has greatly impacted their quality of life. The Plan denied your request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to insufficient evidence of efficacy.
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 surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review indicates that the enrollee has chronic low back pain and lumbar spinal stenosis with neurogenic spinal stenosis. The record indicates that imaging has demonstrated moderate to severe spinal stenosis at L3-4 and L4-5 and mild central stenosis at L2-L3, the level requested for treatment.
The elements of the coverage criteria are not satisfied. The requested service cannot be 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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869), for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and complete lower
denture (D5120).
You asked the Plan to pre-approve the dental services. You say that your dentures were stolen. You say that
you cannot eat. You also say that you need new dentures. The Plan denied your request. The Plan says dentures
are not a covered by Medicare.
Medicare generally does not cover dental services. The Plan follows the same rule.
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement
of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or
paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve a complete upper
denture (D5110) and complete lower denture (D5120).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee orthosis (L1843).

You asked the Plan to pre-approve a knee orthosis. You say that your knee is swelling and crackling. The Plan
denied your request. The Plan says the requirements for coverage have not been met.

The Plan must follow Medicare rules. Medicare rules say that knee orthoses are covered if the beneficiary has
had recent injury to or a surgical procedure on the knee or is ambulatory and has knee instability.

We looked at the file and Medicare rules. The records do not show that you have had a recent surgery or injury
or that you have knee instability. Based on this information, we decided that Medicare rules for coverage of a
knee orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve a knee
orthosis (L1843).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral for out-of-network follow-up visits with hematology/oncology.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says in-network providers are 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 a referral for out-of-network follow-up visits with hematology/oncology.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional routine transportation trips.
You asked the Plan to provide coverage for additional routine transportation trips. You say that you need the
additional rides above the 30 one-way rides to locations other than your PCP because you need rides to your
monthly pain management visits. The Plan denied your request. The Plan says you have exhausted the benefit.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this
case. The Plan covers a maximum of 30 one-way trips per year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we
decided that the Plan does not have to provide coverage for additional routine transportation trips.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that LTACH Admission is medically
necessary. The Plan denied your request. The Plan says the enrollee can receive the same services at the current
level of care.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
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 LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found the documentation does not support that the enrollee in this case requires services at
the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no
required medical services identified that are available at the LTACH, that are not available at the current health
care setting being offered by the health plan.
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 LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation and intraoral complete
series x-ray provided on May 14, 2021.

You asked the Plan to pay for the comprehensive oral evaluation and intraoral x-ray. You say that you paid the
previous x-rays out-of-pocket so they should not be held against you. You say that you want to know why the
x-rays were denied. The Plan denied your request. The Plan says reimbursement has already been issued for
one comprehensive oral evaluation and one intraoral-complete series of radiographic images.

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, you also have a maximum benefit of
one comprehensive oral evaluation every three years and one complete series x-ray every five years. The Plan
paid for the comprehensive oral evaluation and intraoral x-ray provided on February 26, 2020, which exhausted
your benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation
and intraoral complete series x-ray provided on May 14, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the breast ultrasound you had on January
28, 2021.

You asked the Plan to waive the copayment for the ultrasound. You say that you have never had to pay a
copayment for ultrasounds before and that you had this test on the same day as a computed tomography (CT)
scan. The Plan denied your request. The Plan says you were charged separate copayments for the CT scan and
the ultrasound correctly.

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 $35
copayment for x-rays.

Records show that you had both a CT scan and an ultrasound on the same day. You were charged a $175
copayment for the CT scan. You have been asked to pay a $35 copayment for the ultrasound. Your Evidence
of Coverage clearly states that if you get both services on the same day with the same provider, you will be
responsible for both copayments. 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 the breast ultrasound you
had on January 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (D7451, D4273, D4265).

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the requested dental codes are not listed on the dental benefit chart.

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 dental services (D7451, D4273, D4265).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2300, E2311, E2313, E2331, E2377, E2399) for the enrollee.

You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied your request. The Plan says this 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. 

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 accessories. Our reviewer says that the requested accessories are not considered medically reasonable and necessary in this case. Our physician reviewer found E2300 does not serve a primarily medical purpose and is statutorily not covered. The E2377, E2313, E2311 expandable controller and harness are not medically necessary, as the documentation does not reveal that the enrollee requires other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-proportional input devices (e.g., sip and puff, head array, etc.). The enrollee does not need to operate 3 or more powered seating actuators through the drive control, a separate display (i.e., for alternate control devices), other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. The enrollee's strength (with documentation of good grip strength per physician documentation) and function indicates that the enrollee can control any power options through their own individual switches. E2331 attendant control cannot be covered in addition to a beneficiary-operated joystick. The E2399 cannot be approved, as it is already included with the requested E2377, and is not medically necessary and does not need to be requested separately. 

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 accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2300, E2311, E2313, E2331, E2377, E2399) for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (71045) provided on April 23, 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 71045
has a bundled relationship with code 36556 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 (71045) provided on April 23, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically
necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
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 LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found there is no documentation provided necessitating admission to a LTACH. You are
receiving appropriate care at the present acute care hospital. You do not require services at the LTACH that are
not available at the present setting where you are currently receiving care. There are no services available at the
LTACH that you require that are not available at the health care setting being offered by the health plan.
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 LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH services
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation and extraction to be provided by an oral
surgeon.
You asked the Plan to pre-approve the consultation and extraction. You say that your dentist will not provide
the extraction and has referred you to an oral surgeon. You also say that you cannot afford the cost of the
extraction. The Plan denied your request. The Plan says services provided by an oral surgeon are not covered.
The Plan also says that your contract only provides coverage for dental services when they are performed by a
participating general dentist.
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 anyone other than a participating general dentist. Therefore, we decided that
the Plan does not have to pre-approve a consultation and extraction to be provided by an oral surgeon.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH)
for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan
denied your request. The Plan says they will continue to cover medically necessary acute and critical care at the
current facility until the enrollee's condition is stable for transfer to an alternate level of care.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
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 LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found as of the most recent documented medical records, the enrollee does not appear to be
stable for transfer to an LTACH. There is no documentation provided necessitating admission to a LTACH.
The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require
services at the LTACH that are not available at the acute care hospital where she is currently receiving care.
There are no services available at the LTACH that the enrollee requires that are not available at the health care
setting being offered by the health plan. The requested LTACH services are not medically necessary,
reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and
effectively only on an inpatient basis.
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 LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve admission to a long-term acute care hospital (LTACH) for the enrollee.