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

We decided that the Plan does not have to pay for the shoulder elbow wrist hand orthosis provided on January 2, 2020.
You asked the Plan to pay for the shoulder elbow wrist hand orthosis. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the documentation did not indicate that the provider discussed the need for this billed supply code.
The Plan must follow Medicare rules. Medicare rules say that for any DMEPOS item to be covered by Medicare, the patient's medical record must contain sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use or replacement (if applicable).
We looked at the file and Medicare rules. Review of the file shows that the documentation submitted did not indicate that the provider discussed the need for the billed supply code. Therefore, this code cannot be verified. Based on this information, we decided that Medicare rules for coverage of the shoulder elbow wrist hand orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the shoulder elbow wrist hand orthosis provided on January 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the ankle/foot orthoses provided to the enrollee on January 10, 2020.
You asked the Plan to pay for the orthoses. The Plan denied your request. The Plan says that there was no valid proof of delivery.
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 pay for the orthoses. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. The documentation does not support that the ankle/foot orthoses were medically reasonable and necessary in this case, as there is no documentation of a physical examination of the ankles. There is no documentation that enrollee requires stabilization for medical reasons and has the potential to benefit functionally. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for these orthoses. 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 orthoses have not been met. Therefore, we decided that the Plan does not have to pay for the ankle/foot orthoses provided to the enrollee on January 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 2D oral or facial photographic image (D0350) provided on October 21, 2019.
You asked the Plan to pay for the dental service. You say that you were never advised that the special x-ray that you received would not be covered. You also say that you would not have had the x-ray had you known. The Plan denied your request. The Plan says the 2D oral or facial photographic image 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 2D oral or facial photographic image is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 2D oral or facial photographic image (D0350) provided on October 21, 2019.
There is no enrollee liability for this service.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthoses and suspension sleeves provided on November 21, 2019.
You asked the Plan to pay for the knee orthosis (L1833RT) and suspension sleeve (L2397RT). You say that the orthoses were medically necessary. The Plan denied your request. The Plan says the enrollee had the same orthoses still under reasonable useful lifetime.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary.
The file shows that the enrollee had the knee orthosis (L1833RT) and suspension sleeve (L2397RT) at the time the knee orthosis (L1833RT) and suspension sleeve (L2397RT) was received from you. The knee orthosis (L1833RT) and suspension sleeve (L2397RT) serves the same purpose as the knee orthosis (L1833RT) and suspension sleeve (L2397RT) at issue. These orthoses are still within the 5-year RUL and the documentation submitted does not show that the orthoses are irreparably worn, irreparably damaged, or that the enrollee had a change in medical condition to warrant the orthoses at issue. Based on the records provided, there is no indication the orthoses provided met Medicare coverage criteria for replacement at the time of issue. Medicare coverage criteria for orthoses replacement were not met. Therefore, we decided that the Plan does not have to pay for the knee orthoses and suspension sleeves
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided on July 23, 2019 and August 29, 2019.
You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that you disagree with the charges. 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 20% coinsurance for Medicare Part B prescription drugs. You received a Medicare Part B drug on July 23, 2019. The allowed amount is $9,080.94 and 20% of that is $1,816.19. You received a Medicare Part B drug on August 29, 2019. The allowed amount is $4,540.47 and 20% of that is $908.09. The total amount you owe is: $2,724.19. You have been asked to pay the total coinsurance amount of $2,724.19 for Medicare Part B drugs. Medicare Part B drugs fall within the Medicare Part B prescription drugs 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 coinsurance for Medicare Part B drugs provided on July 23, 2019 and August 29, 2019
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve waterjet prostate ablation for the enrollee.
You asked the Plan to pre-approve the requested services. You say that aquablation offers more precise tissue
targeting without heat. The Plan denied your request. The Plan says long-term evidence of its effectiveness and
treatment rates remains limited.
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 the support for use of Transurethral waterjet ablation of prostate, in men with benign
prostatic hyperplasia is quite weak. Further trials comparing Transurethral waterjet ablation of prostate to
standard procedures are needed to determine their long-term efficacy and superiority compared to standard
treatments. Therefore, the requested services are not medically reasonable and 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 the requested services have not been met. Therefore, we decided that the Plan
does not have to pre-approve waterjet prostate ablation for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the interim complete maxillary denture and interim complete mandibular denture provided on November 27, 2019.
You asked the Plan to pay for the interim complete maxillary denture and interim complete mandibular denture. You say that the plan you were on covered dentures. The Plan denied your request. The Plan says these services are not covered under the Plan.
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 interim complete maxillary denture and interim complete mandibular denture provided on November 27, 2019.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for bladder testing provided on September 18, 2019.
You asked the Plan to pay for bladder test. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says that the denial of payment for this service is correct, because this test is experimental/investigational and not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not specify whether the ordering physician was in-network or out-of-network with the Plan. The documentation submitted does not include prior notice that this testing would not be covered. Without this information, we cannot determine whether the lab order made constitutes plan-directed care, which would justify coverage of this testing. Therefore, the Plan has not shown that its decision to deny payment for this testing is correct or justified by Medicare rules. Therefore, we decided that the Plan has to pay for bladder testing provided on September 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the foot inserts purchased on June 27, 2019.
You asked the Plan to reimburse you for the foot inserts. You say that the orthotics gave you good balance and less stress on your feet. The Plan denied your request. The Plan says if your suppliers aren't enrolled in Medicare the claims submitted are not payable.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items provided directly by a provider who is not eligible to take Medicare payment. The items at issue in this appeal were provided by a provider not certified by Medicare. Therefore, we decided that the Plan does not have to reimburse you for the foot inserts purchased on June 27, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on December 19, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the claim was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of
service (POS) code.
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for an
independent laboratory; however, the file shows that the specimen was obtained in an office setting and should
have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory
services rendered on December 19, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the upper GI endoscopy provided by on January 8, 2020.
You asked the Plan to reduce the copayment for the upper GI endoscopy. You say that you had the procedure done at an ambulatory surgical center and should have a $325 copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $425 copayment for each Medicare-covered visit to an outpatient hospital facility. You have been asked to pay a $425 copayment for the upper GI endoscopy. The upper GI endoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows you were billed by the outpatient hospital.
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 reduce the copayment for the upper GI endoscopy provided on January 8, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the paramedic intercept services.
You asked the Plan to pay for the paramedic intercept services. You say that on the ambulance transport you were told that the paramedics were called to intercept the ambulance because it was necessary to use an IV because of your high blood pressure. You say that you were twenty five miles from the hospital and it was necessary to do it as soon as possible. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare pays for advanced life support (ALS) paramedic intercept services only when the services are furnished under a contract with a qualified basic life support (BLS) volunteer ambulance company. In addition, State law must not allow the volunteer ambulance company to bill for the transport or BLS services. The Plan has confirmed that the company does not have a contract with the volunteer ambulance company that provided the transport services. Therefore, we decided that the Plan does not have to pay for the paramedic intercept services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on August 8, 2019 to September 6, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the physician 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 provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care. We looked at the file and Medicare rules. The file shows that the services provided were neither emergent nor urgent and were not due to an unforeseen illness or condition. This was routine care. Based on this information, we decided that Medicare rules for coverage of the physician services have not been met. Therefore, we decided that the Plan does not have to pay for the physician services provided on August 8, 2019 to September 6, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on January 9, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the enrollee
must receive care from in-network providers with the exception of emergency or urgent care, dialysis while
temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which
requires prior authorization from the plan.
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 physician's services provided on January 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve crown - porcelain fused to high noble metal (D2750) on tooth 11.
You asked the Plan to pre-approve the dental service. You say that a crown is highly recommended in order to prevent possible tooth break down. The Plan denied your request. The Plan says the crown is not reasonable or necessary and does not meet the coverage criteria.
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 dental service 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 dental service. Our reviewer says the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found due to the extent and location of the recurrent caries on tooth #11 resulting in a poor prognosis for a crown (D2750), the criteria for coverage have not been met. 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 dental service have not been met. Therefore, we decided that the Plan does not have to pre-approve crown - porcelain fused to high noble metal (D2750) on tooth 11.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the comprehensive oral evaluation provided on December 12, 2019.
You asked the Plan to pay for the comprehensive oral evaluation. You say that you were under the impression that this was a cleaning and not an exam. The Plan denied your request. The Plan says that your benefit maximum has been met.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. the Plan follows these rules. You were referred for the comprehensive oral evaluation by an in-network provider. The Plan contract states that you have coverage for one comprehensive oral exam every 36 months. However, you say that you were unaware of the type of exam that was being given to you by the participating provider. It is reasonable that you would have expected a participating provider to only supply you with an oral exam for which you had coverage. Medicare rules say that when a service could be covered under some conditions, the EOC alone is not adequate notice of coverage. The file does not show that the Plan provided notice that the comprehensive oral evaluation would not be covered. Under Medicare rules, this means the comprehensive oral evaluation is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the comprehensive oral evaluation provided on December 12, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a screening mammogram (77067) provided September 6, 2019.
You asked the Plan to pay for the mammogram. You say that services were medically necessary and correctly billed. The Plan denied your request. The Plan says the claim submitted was billed incorrectly.
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 77067 is not supported in the medical record. Specifically, the place of service billed (Emergency Room) is not valid for the service performed (Screening Mammogram). Based on this information, we decided that Medicare rules for coverage of the mammogram have not been met. Therefore, we decided that the Plan does not have to pay for a screening mammogram (77067) provided September 6, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on June 23, 2019 by an out of network (OON) provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by an out-of-network provider without 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 has network providers available who can provide 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 medical services provided on June 23, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthoses and suspension sleeves provided on January 2, 2020. You asked the Plan to pay for the knee orthoses (L1833) and suspension sleeves (L2397). You say that the orthoses were medically necessary. The Plan denied your request. The Plan says the documentation submitted did not indicate the provider discussed the need for the billed supply codes, therefore the billed supply codes cannot be verified. 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 medical records do not mention or support medical necessity for the orthoses. Based on this information, we decided that Medicare rules for coverage of the knee orthoses (L1833) and suspension sleeves (L2397) have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthoses and suspension sleeves provided on January 2, 2020.