Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a leg pump 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 that no trial of the leg pump was conducted.

The Plan must follow Medicare rules. Medicare rules say that services are covered when they are medically necessary. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found in this case the enrollee has a diagnosis of lymphedema with hyperpigmentation. She has failed more than a four week trial of exercise, leg elevation, and compression as indicated by the provided measurements. The requested service is 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 device have been met.Therefore, we decided that the Plan has to pre-approve a leg pump device for the enrollee.

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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the inpatient hospital stays provided from March 31, 2020 to April 16, 2020 and from April 20, 2020 to April 26, 2020.
You asked the Plan to waive the copayments for the inpatient hospital stays. You say that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says the enrollee received inpatient hospital care on the dates of service at issue in this appeal. The Plan says that the correct copayments have applied per the enrollee's contract with the Plan.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $380 copayment per day for days 1-5 for Inpatient hospital care. We looked at the file, the Plan's contract and Medicare rules. The file shows that the enrollee received inpatient hospital care from March 31, 2020 to April 16, 2020 and from April 20, 2020 to April 26, 2020. The enrollee has been asked to pay a $380 copayment per day for days 1-5 for the inpatient hospital stays, totaling $3800 for both inpatient stays. The inpatient hospital stays fall within the Inpatient hospital care benefit category. This means that the enrollee has been asked to pay the correct amounts based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Medicare does not require Plans to waive cost share obligations for the treatment of COVID. The file contains no information that the Plan waives cost share for the treatment of COVID. Therefore, we decided that the Plan does not have to waive the copayments for the inpatient hospital stays provided from March 31, 2020 to April 16, 2020 and from April 20, 2020 to April 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assistant surgeon services provided on September 22,
2020.
You asked the Plan to pay for the assistant surgeon services. You say that you would like the Plan to reconsider
their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1,
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current
Procedural Terminology (CPT) code 41112. The Medicare Fee Schedule Database contains a surgical indicator
of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically
necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the
assistant surgeon services have not been met. Therefore, we decided that the Plan does not have to pay for the
assistant surgeon services provided on September 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown (D2790).
You asked the Plan to pay for the crown. You say that you needed the crown due to having a broken tooth. The Plan denied your request. The Plan says the requested item is not covered under your supplemental 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, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the crown (D2790).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the fluid circulating cold pad with pump (E0218) provided on November 5, 2020 and November 26, 2020.
You asked the Plan to pay for the fluid circulating cold pad with pump. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the item is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. The rules say a fluid circulating cold pad with pump (E0218) will be denied as not reasonable and necessary. Therefore, we decided that the Plan does not have to pay for the fluid circulating cold pad with pump (E0218) provided on November 5, 2020 and November 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on September 3, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says nonemergent,
non-urgent services with out-of-network providers require prior authorization.
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 did not pre-approve the
physician's services. We found no exception that would require the Plan to pay for these services. Therefore,
we decided that the Plan does not have to pay for physician's services provided on September 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids (V5261) provided December 3, 2020.
You asked the Plan to pay for the hearing aids. You say that you were not given complete information that you needed to go to an in-network provider and therefore the Plan should provide coverage. The Plan denied your request. The Plan says you did not go to one of the Plan's vision vendor's network providers and therefore the hearing aids are not covered.
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 you see a hearing network provider. We looked at 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. Therefore, we decided that the Plan does not have to pay for the hearing aids (V5261) provided December 3, 2020.
Your complaint about potentially receiving incomplete information from 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit services provided on November 16, 2020.

You asked the Plan to pay for the office visit services. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services are not covered as billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.

We looked at the file and Medicare rules. The Global Surgery Package includes follow-up evaluation and management visits during the postoperative period of the surgery that are related to recovery from the surgery. In this case, code 99213 was bundled as part of the global surgical package of major procedure code 28820. Review of the records indicates that the service performed was unrelated to the major procedure performed on September 24, 2020. However, code 99213 was not billed with the appropriate "24" modifier indicating that the denied service was unrelated and rendered during the post-operative period of a global procedure.Therefore, we decided that the Plan does not have to pay for the office visit services provided on November 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic ophthalmic ultrasound (76514) and the computerized ophthalmic diagnostic imaging (92133, 92134) provided on October 27, 2020.
You asked the Plan to waive the copayment for the diagnostic eye services. You say that you understand that you should have your copayment for the visit with your ophthalmologist, but you do not understand why the imaging services also have copayments. You say these are medically necessary and were part of your overall routine eye exam that you require to monitor your pre-existing eye conditions. The Plan denied your request. The Plan says each Medicare-covered eye exam to diagnose and treat diseases and conditions of the eye require is subject to a $35 copayment.
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 each Medicare-covered eye exam to diagnose and treat diseases and conditions of the eye. You have been asked to pay a $35 copayment or less for each of the diagnostic eye imaging services. You say this is part of your routine exam, however a routine exam or screening is provided when there is no sign of a problem or injury. You have pre-existing conditions that require monitoring, and these services were billed as diagnostic imaging services, which means that these imaging services are considered diagnostic rather than routine. The Plan requires a $35 copayment for each Medicare-covered eye exam to diagnose and treat diseases and conditions of the eye. 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 diagnostic ophthalmic ultrasound (76514) and the computerized ophthalmic diagnostic imaging (92133, 92134) provided on October 27, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the respiratory viral panel, 3-5 targets, described by code
87631 provided on February 12, 2020.

You asked the Plan to pay for code 87631. You say that you would like the Plan to reconsider their denial of
payment. The Plan denied your request. The Plan says the services are not covered as billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The
rules say that diagnosis codes must be billed with the most precise code that most fully explains the narrative
description of the symptom or diagnosis.

We looked at the file and Medicare rules. In this case, the claim was billed with code 87631 with a diagnosis
code of Z20.828. This diagnosis code was not payable with code 87631 until February 20, 2020. The services
in this case were provided before this diagnosis code was valid for code 87631. Therefore, we decided that the
Plan does not have to pay for the respiratory viral panel, 3-5 targets, described by code 87631 provided on
February 12, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray (72100) provided September 16, 2020.
You asked the Plan to pay for the x-ray. You say that the x-ray was medically necessary. The Plan denied your request. The Plan says the claim was not filed correctly.
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 find that CPT code 72100 is not supported in the medical record. Specifically, no professional component was billed for the service. Based on this information, we decided that Medicare rules for coverage of the x-ray have not been met. Therefore, we decided that the Plan does not have to pay for an x-ray (72100) provided September 16, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient services (99254) provided April 16, 2020.
You asked the Plan to pay for the inpatient services. You say that the services were medically necessary. The Plan denied your request. The Plan says the CPT code billed is not eligible for Medicare payment.
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 find that CPT code 99254 is not supported in the medical record. Specifically, per the 2020 National Physician Fee Schedule, this CPT code has a status code of "I" which means it is not valid for Medicare payment. Based on this information, we decided that Medicare rules for coverage of the inpatient services have not been met. Therefore, we decided that the Plan does not have to pay for inpatient services (99254) provided April 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar epidural injection.
You asked the Plan to pre-approve lumbar epidural injection. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because there were no indications provided for the medical necessity of this injection.
The Plan follows Medicare rules. Medicare rules say that lumbar epidural injections may be covered under certain indications. 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 lumbar epidural injection. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested lumbar epidural injection. Our physician reviewer found the physical examination does not detail the signs and symptoms of lumbar radiculopathy, (motor, sensory, reflexes, are not detailed). Magnetic Resonance Imaging (MRI) or other imaging were not submitted for review. The enrollee had an epidural steroid injection on November 12, 2020, but the degree and duration of the effectiveness of this injection are not detailed. There is a lack of
documentation in the record and therefore, at this time, the request is considered 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 lumbar epidural injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a lumbar epidural injection.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs and to waive the cost share for the outpatient therapy and outpatient surgery provided from October 19, 2020 to October 20, 2020.
You asked the Plan to pay for the self-administered drugs and to waive the cost share for the outpatient therapy and outpatient surgery. You say that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received self-administered drugs, outpatient therapy and outpatient surgery on the dates of service at issue in this appeal.
The Plan says that self-administered drugs are not covered under your Medicare Part B benefit. The Plan also says that the correct cost share has applied per your contract with the Plan.
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 $40 copayment for Outpatient rehabilitation services and a 20% coinsurance for each covered surgery or observation room service in an outpatient hospital. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received outpatient therapy and outpatient surgery in an outpatient hospital facility from October 19, 2020 to October 20, 2020. You have been asked to pay a $40 copayment for the outpatient therapy services. The outpatient therapy services fall within the Outpatient rehabilitation services benefit category. You have also been asked to pay a 20% coinsurance for the outpatient surgery, totaling $2220.91. The outpatient surgery falls within the Outpatient surgery benefit category. This means that you have been asked to pay the correct amounts based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. The rules also say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs provided here are not among the types which are covered by Medicare Part B.
Therefore, we decided that the Plan does not have to pay for the self-administered drugs and to waive the cost share for the outpatient therapy and outpatient surgery provided from October 19, 2020 to October 20, 2020.
Benefits for the self-administered drugs and to waive the cost share for the outpatient therapy and outpatient surgery 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for one of the podiatry services provided on November 12, 2020.

You asked the Plan to waive the copayment for one of the podiatry services. You say that you usually only pay one copayment.The Plan denied your request. The Plan says you were charged the copayments 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 $25 copayment for Podiatry Services. 

You have been asked to pay a $25 copayment for each podiatry service. The services fall within the Podiatry Services benefit category. The provider submitted the claim for two services. 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 one of the podiatry services provided on November 12, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for the surgical procedure with code 62370-LT provided on December 15, 2020.

You asked the Plan to pay for code 62370-LT. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says that the services are not covered as billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.

We looked at the file and Medicare rules. The American Medical Association (AMA) considers code 62370 to be a surgical code. Medicare follows this guidance. The file shows in the operative report that code 62370 was performed on the left side.Therefore, we decided that the Plan has to pay for the surgical procedure with code 62370-LT provided on December 15, 2020.

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 pay for a domiciliary, rest home visit provided on
December 20, 2019.
You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.
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 did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for a domiciliary, rest home visit provided on December 20, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement of the copayment for the computed tomography (CT) scan of the head or brain, without contrast (70450) provided on January 15, 2021.
You asked the Plan to issue reimbursement of the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.
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 $75 copayment for advanced imaging services rendered by an in-network provider. You have been asked to pay a $75 copayment for the advanced imaging service provided. 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 issue reimbursement of the copayment for the computed tomography (CT) scan of the head or brain, without contrast (70450) provided on January 15, 2021.