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

We decided that the Plan does not have to pay for an excision of benign lesion (D7410), and a resin-based composite (D2393) provided by an out-of-network provider on August 3, 2021.

You asked the Plan to pay for an excision of benign lesion and a resin-based composite. You say that you think that the Plan should pay for this. The Plan denied your request. The Plan says the correct coinsurance has been applied. The Plan says that D7410 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, D7410 is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an excision of benign lesion (D7410). There is a 55% coinsurance for a resin-based composite (D2393). The total allowed amount for D2393 is $163. The total amount you are being asked to pay for D2393 is $89.65 ($163 x 55%= $89.65). The total amount you are being asked to pay for D2393 and D7410 is $686.65 ($597 + $89.65 = $686.65) provided by an out-of-network provider on August 3, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an echocardiography provided on August 20, 2019. 
 
You asked the Plan to pay for the echocardiography. The Plan denied your request. The Plan says the claim 
was submitted past the allowed 12 month timeframe. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the echocardiography was not filed until July 9, 2021. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for an echocardiography provided on August 20, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a resin-based composite-two surfaces, posterior (D2392)
provided by a participating provider on February 1, 2021.

You asked the Plan to pay for a resin-based composite-two surfaces. You say that you believe this should be
covered 100%. The Plan denied your request. The Plan says the benefit limit for crowns has already been
exhausted this calendar year.

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 resin-based
composite-two surfaces twice a calendar year.

We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for
coverage of a resin-based composite-two surfaces have not been met. Evidence was provided that showed this
benefit has already been exhausted on February 1, 2021, with tooth #19 and #20.

Therefore, we decided that the Plan does not have to pay for a resin-based composite-two surfaces, posterior
(D2392) for tooth #18 provided by a participating provider on February 1, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the clinical documentation provided 
supports the need for an LTACH admission. The Plan denied your request. The Plan says the guidelines for 
coverage of LTACH care have not been met. The Plan says that the services needed could be provided in 
another setting. 
 
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 enrollee appears to be stable and improving with current care. She only requires 
short-term additional acute care services that can be safely administered at the current facility. The enrollee 
does not require services at the LTACH that are not already available at the current facility. There are no 
services at the LTACH that the patient requires that are not already available and covered at the current facility. 
Transfer to an LTACH will be considered not medically necessary at this time as there would be no clinical 
advantage to doing so. Transfer to a lower level of care may be considered soon when treatment has completed.  
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 long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to provide coverage for acute inpatient hospital care to be provided 
after an elective left total knee arthroplasty. 
 
You asked the Plan to provide coverage for acute inpatient hospital care. The Plan denied your request. The 
Plan says based on Medicare guidelines and the information we have about the enrollee's condition the care 
could be provided without an inpatient stay after the surgical procedure. 
 
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 provide coverage for acute inpatient hospital care.  Our reviewer says that the documentation does not support that the criteria for inpatient care are met in this 
case. Our physician reviewer found that the enrollee is an 81-year-old female with left knee pain and primary 
osteoarthritis of left knee who has failed conservative therapy. The health Plan feels that the services are 
reasonable and medically necessary for the treatment of the enrollee. She is undergoing a planned left total 
knee arthroplasty. The enrollee is medically stable and has been provided medical clearance to undergo this 
elective procedure. The planned procedure listed under CPT code 27447 is not listed on the CMS Inpatient 
Only List. The procedure is currently approved as an ambulatory procedure. There is no documentation 
provided to support the expectation the enrollee will require a greater than 2 midnight stay. The review has 
determined that the record show does not that the admitting physician reasonably expects 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 provide coverage for acute inpatient hospital care to be provided after an elective left 
total knee arthroplasty.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve the deep sedation. 
 
You asked the Plan to pre-approve the deep sedation. You say that you need to be put to sleep during the 
procedure. You say that you have a $2,000 allowance for dental and should be allowed to use it for anesthesia. 
The Plan denied your request. The Plan says that 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. The Plan covers up to $3,500 
per year for dental services and anesthesia is listed as a covered service. 
 
We looked at Evidence of Coverage, the dental contract, the file, and Medicare rules. Based on this 
information, we decided that the Plan's rules for coverage of the deep sedation have been met. Specifically, the 
dental contract clearly lists anesthesia as a covered benefit. The Plan has not submitted any documentation 
showing deep sedation is not a covered service or that anesthesia is only covered when medically necessary. 
Therefore, we decided that the Plan has to pre-approve the deep sedation.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiovascular risk assessment testing provided on May 
26, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that coverage for all CV risk assessment panels, 
except the basic lipid panel, is denied for symptomatic (with signs and symptoms) patients with suspected or 
documented CV disease because panel testing is not specific to a given patient?s lipid abnormality or disease.  
 
We looked at the file and Medicare rules. Per LCD L36358, the requested cardiovascular risk assessment 
testing is not a covered service. Based on this information, we decided that Medicare rules for coverage of the 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk 
assessment testing provided on May 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an auricular stimulator. 
 
You asked the Plan to pre-approve an auricular stimulator. You say that the requested procedure is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested procedure is not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that electro-acupuncture devices used for stimulation 
of auricular acupuncture points are non-covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an auricular stimulator have not been met. Specifically, the requested item is an electro-
acupuncture device which is not a covered benefit. Therefore, we decided that the Plan does not have to pre-
approve an auricular stimulator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and adjunctive pre-diagnostic test (D0431) provided on June 9, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the periodic oral evaluation and adjunctive pre-diagnostic test. You say that there are not a lot of participating providers in your area. The Plan denied your request. The Plan says services performed by an OON provider are not covered because your healthcare plan does not have OON benefits. The Plan also says that you did not contact the Plan prior to this date of service to verify benefits and provider eligibility.

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 are responsible for 100% of the cost for dental services rendered by an OON provider. The record shows that there are twenty in-network dentists within a five-mile radius of your home. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and adjunctive pre-diagnostic test (D0431) provided on June 9, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crutch substitute, lower leg platform, with or without wheels (E0118).

You asked the Plan to pre-approve a crutch substitute. You say that that your doctor ordered you a roll around scooter. You need the scooter to get around easier. You have a diabetic ulcer on your right foot. You cannot have any weight on your foot. The Plan denied your request. The Plan says this item is not covered by Medicare or the Plan as there is insufficient evidence in its safety and effectiveness to establish the medical necessity for these products.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a crutch substitute have not been met. Therefore, we decided that the Plan does not have to pre-approve a crutch substitute, lower leg platform, with or without wheels (E0118).
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 this is medically necessary. The Plan denied your 
request. The Plan says the services can be safely received in other settings, for example, a skilled nursing 
facility, home with home health services, or home with outpatient therapy. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. 
 Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee was admitted for lumbar spine surgery. Medical problems are stable. There are no complex nursing or 
rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record 
supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a 
reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre therapeutic continuous glucose 
monitor (CGM). 
 
You asked the Plan to pre-approve therapeutic CGM. You say that you only have one hand with the sensation 
to test your glucose and the majority of the time blood does not come out due to your past condition. The Plan 
denied your request. The Plan says you do not meet the Medicare criteria for a therapeutic continuous glucose 
monitor. 
 
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 the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of therapeutic CGM have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a Freestyle Libre therapeutic continuous glucose monitor 
(CGM).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on October 20, 2020. 
 
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 procedure code 86001 is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 86001 is allergen specific IgG quantitative or 
semiquantitative, each allergen. 
 
We find that CPT code 86001 is not supported in the medical record. Specifically, there is no documentation of an allergen specific IgG quantitative or qualitative testing. Based on this information, we decided that Medicare 
rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to 
pay for the laboratory services rendered on October 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of aquatic therapy coded as 97113 and 97110.
You asked the Plan to pre-approve aquatic therapy. You say that you previously had aquatic therapy and had benefited from it. The Plan denied your request. The Plan says while there might be a benefit to a specific form of physical therapy, the medical necessity for continued therapy requires evaluation of the enrollee's specific condition.
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 aquatic therapy. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found While there might be a benefit to a specific form of physical therapy, the medical necessity for continued therapy requires evaluation in the enrollee's specific condition. The physical therapist will need to provide an assessment and a treatment plan as well as confirmation of the skilled need. The Plan did however, approve an aquatic evaluation and consultation with the physical therapist. The review has determined that the items/services at issue in this case are 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 aquatic therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of aquatic therapy coded as 97113 and 97110.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says based on the enrollee's current level of function, the enrollee has not had a change in function that needs daily skilled therapy services. The Plan states no daily skilled nursing needs are noted, and their needs may be met at a lower level of care. The Plan states the services they need may safely be received from home health services and supervision at home or in an assisted living facility. The Plan states the
enrollee's needs may also be met from part-time skilled services in long-term care and home health and part-time skilled services would need to be approved by the enrollee's health plan.
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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not qualify for SNF coverage. The enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee is ambulating household distances and tending to activities of daily living (ADLs) with minimal supervision. The enrollee's care needs, as a practical matter, can be provided at a lower 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided from March 28, 2021, to 
April 25, 2021. 
 
You asked the Plan to pay for the home health services. You say that you feel these services should be covered 
due to the care you were provided with in the nursing facility. The Plan denied your request. The Plan says 
custodial care is not covered by Medicare or the Plan. The Plan also says that you self-arranged for 24-hour 
home giver care to provide services for activities of daily living. 
 
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. The rules also say that the provider, supplier, or beneficiary, as appropriate, must 
furnish to the intermediary or carrier sufficient information to determine whether payment is due and the 
amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health services have not been met. Without medical documentation there is insufficient 
information to determine if Medicare coverage criteria for the home health services have been met. Therefore, 
we decided that the Plan does not have to pay for the home health services provided from March 28, 2021, to 
April 25, 2021.  
 
Your complaint about the terrible conditions and service you experienced at the acute care facility 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.