Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says there are currently no clinical indications for this technology.
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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found current evidence based medical guideline and peer reviewed literature do not fully support the spinal decompression device procedure over the 'gold standard' of lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollee's medical condition as discussed above. There is imaging evidence of moderate to moderately severe convex left lumbar scoliosis, apex at L2 of the lumbar spine with no documentation of the Cobb angle. There is no discussion indicating that a DEXA scan has demonstrated the lack of significant osteoporosis in this enrollee. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines.
Therefore, the request for Vertiflex Superion interspinous device at L2-3 and L3-4 levels is not medically reasonable or necessary.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient rehabilitation stay from April 14, 2021, to April 29, 2021.
You asked the Plan to waive the copayment for the inpatient rehabilitation stay. You say that you were told by the Plan that the facility would provide services with no cost to you for the first 20 days. The Plan denied your request. The Plan says the copayment was applied 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 $295 copayment each day for days 1 to 6 of Medicare covered hospital care. You have been asked to pay a total of $1,770 ($295 copayment x 6 days = $1,770) for the inpatient
rehabilitation stay. This stay falls within the Inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient rehabilitation stay from April 14, 2021, to April 29, 2021.
Your complaint about potentially being provided misinformation by a Plan representative 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: 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. The Plan denied your request. The Plan says the enrollee does not need to be seen by a rehabilitation doctor 3 times a week, or an intensive team for 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 physician reviewer found that you are at a minimal assist level for sitting up, moderate assist for transfers, and contact guard assist for lying down. You do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation.

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 initial periapical x-ray (D0220), the additional periapical
x-ray (D0230), oral or facial photographic image (D0350), and the comprehensive oral evaluation (D0150)
provided on May 17, 2021.
You asked the Plan to pay for the x-rays. You say that you believe you should not owe anything. You say that
this was your first visit to this dentist. You also say that you believe you did not request additional services and
was not told about them or that you would be charged for them. The Plan denied your request. The Plan says
periapical x-rays are not listed as covered services. The Plan also says that oral or facial photographic image 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 periapical x-rays and photographic
image are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay
for the initial periapical x-ray (D0220), the additional periapical x-ray (D0230), oral or facial photographic
image (D0350), and the comprehensive oral evaluation (D0150) provided on May 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on June 8, 2021.
You asked the Plan to pay for the limited evaluation. You say that you were not aware of this rule. The Plan denied your request. The Plan says they paid for a previous limited oral exam which was provided in March 2021. This service can only be covered once per year. Therefore, the second limited oral exam you received on the date in question is denied for payment.
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 limited exam to evaluate a problem (D0140) per plan year.
Though the Plan offers a dental benefit in excess of Medicare coverage, the limited oral exam is requested in a frequency that exceeds what is covered under this benefit. Documentation shows that the Plan has already paid for one limited oral evaluation for you in 2021. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on June 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the back brace provided on November 24, 2020.

You asked the Plan to pay for the back brace. The Plan denied your request. The Plan says this service is not supported by the medical record.

The Plan must follow Medicare rules. The rules state that spinal orthoses are only covered under certain medical indications. 

We looked at the file and the rules. The medical records do not support medical necessity for the supplies provided in this case. Specifically, the records do not show that the item at issue was ordered for a covered indication. Based on this information, we decided that the Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the back brace provided on November 24, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous spacer device.

You asked the Plan to pre-approve the requested services. You say that you will have less side effects with this
procedure. The Plan denied your request. The Plan says unproven and not medically necessary procedures are
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 requested services. Our physician
reviewer found that in this case, you have chronic low back pain and lumbar spinal stenosis with neurogenic
claudication. The record indicates that imaging has demonstrated multi-level severe spinal stenosis. The record
documents that you are indicated for operative intervention at more than two levels. The records do not show
the requested service is indicated for your condition. The documentation does not support the requested service
is medically reasonable or necessary at this time.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous spacer device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910), the additional periapical x-ray (D0230), the oral or facial photographic image (D0350), and topical application of fluoride varnish (D1206) provided on May 4, 2021.

You asked the Plan to pay for the dental services. You say that you went for a cleaning and x-rays. You say that you did approve the fluoride treatment. You say that you did not approve any other extras. You say that you feel you should not be responsible for anything besides the fluoride treatment. You also say that this was the worst cleaning you have ever had. The Plan denied your request. The Plan says 1 periapical x-ray is covered per calendar year. The Plan says that the frequency limit has been exceeded. The Plan says that periodontal maintenance, oral or facial photographic image, and fluoride varnish application are not listed as covered services.

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 and periapical x-ray is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for the initial periapical x-ray that you received on the date of service in this case. Additionally, the periodontal maintenance, oral or facial photographic image, and fluoride varnish application are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the periodontal maintenance (D4910), the additional periapical x-ray (D0230), the oral or facial photographic image (D0350), and topical application of fluoride varnish (D1206) provided on May 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve root canals (D3330) for tooth #'s 18 and 19.
You asked the Plan to pre-approve the root canals. You say that you have toothaches and are unable to eat properly. The Plan denied your request. The Plan says the root canals are not medically necessary because extensive decay and furcation involvement render tooth #'s 18 and 19 non-restorable.
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 root canals when the services are medically necessary and reasonable. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the root canals. Our reviewer says that the documentation provided does not support the criteria for coverage for root canals on teeth #'s 18 and 19 due to the poor prognosis of retention of these teeth. Our physician reviewer found the dental x-rays and records
indicate that tooth #'s 18 and 19 do not appear restorable due to the amount of coronal caries and fracture and the poor periodontal prognosis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the root canals have not been met. Therefore, we decided that the Plan does not have to pre-approve root canals (D3330) for tooth #'s 18 and 19.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the scaling in moderate or severe gingival inflammation (D4346) provided on March 12, 2021.

You asked the Plan to pay for the dental service. You say that you received a bill from the dental clinic. The Plan denied your request. The Plan says scaling in moderate or severe gingival inflammation is not listed as a covered service.

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 scaling in moderate or severe gingival inflammation is not among those covered under this benefit.

Therefore, we decided that the Plan does not have to pay for the scaling in moderate or severe gingival inflammation (D4346) provided on March 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the digital hearing aids (V5256) purchased on March 17, 2021.

You asked the Plan to pay for the hearing aids. You say that initially the enrollee did not realize that they needed to purchase hearing aids through a specific provider but returned the previous pair after learning this information. Unfortunately, none of the hearing aids from the specified vendor fit properly, and they had to return to the out-of-network provider. The Plan denied your request. The Plan says hearing aids are only covered when they are purchased from the specified in-network vendor.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when they are purchased from the Plan's specified hearing vendor network.

We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. The hearing aids in question were purchased outside of the Plan's specified vendor network. Therefore, we decided that the Plan does not have to pay for the digital hearing aids (V5256) purchased on March 17, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the individual psychotherapy services (90832) provided on February 4, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the psychotherapy services. You say that you have attached the supporting documents. Kindly review and process the claim towards payment. The Plan denied your request. The Plan says there was no documentation of consultation with the attending or primary care physician in the medical records.
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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the individual psychotherapy services (90832) provided on February 4, 2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan provided on May 6, 2021.

You asked the Plan to waive the copayment for a CT scan. You say that you had no choice but to use this
provider due to the coronavirus. The Plan denied your request. The Plan says the claims were processed
correctly, and you are being charged the correct amount.

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 $0
copayment for advanced imaging services provided by a primary care provider and a $40 copayment when
provided by a specialist, outpatient hospital or freestanding radiological facility.

You received a CT scan at a specialist's office on May 6, 2021. Therefore, you are responsible to pay the $40
copayment.

You have been asked to pay a $40 copayment for a CT scan. A CT scan falls within the outpatient diagnostic
tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment
for a CT scan provided on May 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the suspension sleeve (L2397) provided June 4, 2021.

You asked the Plan to pay for the suspension sleeve. You say that you would like this claim reprocessed for
medical necessity. The Plan denied your request. The Plan says the addition code L2397 has denied because the
base orthosis was not identified for the same date of service.

The Plan must follow Medicare rules. Medicare rules say that in order for addition orthotic codes such as
L2397 to be eligible for payment, they must be provided with the related base code orthosis.

We looked at the file and Medicare rules. In this case, there is no evidence of payment for the necessary base
orthosis the suspension sleeve would be associated with. Based on this information, we decided that Medicare
rules for coverage of the suspension sleeve have not been met. Therefore, we decided that the Plan does not
have to pay for the suspension sleeve (L2397) provided June 4, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray provided on November 30, 2020.

You asked the Plan to pay for the x-ray services. You say that the records support this procedure was performed. The Plan denied your request. The Plan says the chest x-ray was previously approved and paid.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

We looked at the file and the rules. We find that CPT code 71046 was previously billed and subsequently paid
for by the Plan. The records provided do not indicate that more than one x-ray was provided on the date of
service at issue. Based on this information, we decided that Medicare rules for coverage of the x-ray services
have not been met. Therefore, we decided that the Plan does not have to pay for the chest x-ray provided on
November 30, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the debridement services and chemical cauterization of
granulation tissue provided on May 19, 2021, by an OON provider.
You asked the Plan to pay for the debridement services and chemical cauterization of granulation tissue. You
say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the
services rendered are not a covered benefit.
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 pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the debridement services and chemical
cauterization of granulation tissue provided on May 19, 2021, by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cataract surgery to be rendered by the 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 render 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 cataract
surgery to be rendered by the OON provider.