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

We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided August 22, 2020.
You asked the Plan to pay for the lumbar-sacral orthosis. You say that the requested item was medically reasonable and necessary. The Plan denied your request. The Plan says there is no evidence prescribing physician ever saw the member.
The Plan follows Medicare rules. Medicare rules say that the spinal orthosis is covered when the Medicare criteria specified in the Rules section is met. 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 lumbar-sacral orthosis. Our reviewer says that the lumbar-sacral orthosis was not medically reasonable and necessary. Our physician reviewer found an appropriate history and a physical examination of the back would reasonably be required to adequately assess whether the coverage criteria for a lumbar-sacral orthosis have been met. The documentation does not
support that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as there is insufficient documentation of a credible evaluation and a credible physical examination of the back. 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 lumbar-sacral orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided August 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series of intraoral x-rays provided on October 15, 2020.
You asked the Plan to pay for the complete series of intraoral x-rays. You say that prior to this date of service you contacted the Plan and were advised that all x-rays were covered. The Plan denied your request. The Plan says this is not a covered service under your plan. The Plan also says that you spoke with them on July 7, 2020 and were given no misinformation.
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. The record shows that you were advised you only have coverage for bitewing x-rays each year. Therefore, we decided that the Plan does not have to pay for the complete series of intraoral x-rays provided on October 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), the complete series x-ray (D0210), and the panoramic x-ray (D0330) provided on October 7, 2020.
You asked the Plan to pay for the dental services. You say that you switched dentists. You say that you requested your dental records from your previous dental office. You say that your new dentist did their own exam. You also say that you were not informed by either party that you would be billed. The Plan denied your request. The Plan says comprehensive oral evaluation, complete series x-ray, and panoramic x-ray is covered once every 3 years. The Plan says that frequency limits for these services have been exceeded.
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 frequency limits have been exceeded. The record shows that the Plan paid for these services that you received on March 9, 2020. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), the complete series x-ray (D0210), and the panoramic x-ray (D0330) provided on October 7, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve laparoscopic conversion to biliopancreatic diversion with duodenal switch (43845) laparoscopic hiatal hernia repair (43281)
You asked the Plan to pre-approve the surgical procedure. You say that you are sincerely requesting the plan reconsider and approve the recommended surgery. In the long run it will improve your health and ability to keep active and productive. The Plan denied your request. The Plan says that the services do not meet medical necessity criteria.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 surgical procedure. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found in this case, the enrollee has recurrent weight gain, gastroesophageal reflux and a hiatal hernia. The enrollee does not have one of the enumerated co-morbid conditions. However, the list, by plain language, is not exclusive to other conditions. The enrollee has morbid obesity with a BMI of over 50. She has completed the appropriate workup and received the required clearances that indicate revision surgery is the best option for her. The requested procedure satisfies the coverage criteria and the requested procedure 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 surgical procedure have been met. Therefore, we decided that the Plan has to pre-approve laparoscopic conversion to biliopancreatic diversion with duodenal switch (43845) laparoscopic hiatal hernia repair (43281)
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for knee arthroscopies (29880).

You asked the Plan to pay for knee arthroscopies. You say that this was billed correctly. The Plan denied your request. The Plan says two units of this code exceed MUE and this should be billed as a single unit with a bilateral modifier.

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied.

In this case, the MUE for CPT code 29880 is 1. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of knee arthroscopies have not been met. Therefore, we decided that the Plan does not have to pay for knee arthroscopies (29880).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for a PET scan, a bronchoscopy and emergency care provided from October 2, 2020, to November 13, 2020.
You asked the Plan to waive the copayments for a PET scan, a bronchoscopy and emergency care. You say that you cannot afford 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 a $300 copayment for diagnostic radiological services. Your contract with the Plan also clearly says that you must pay a $350 copayment for outpatient surgery, including services provided at ambulatory surgical centers and outpatient hospital facilities. Your contract with the Plan also clearly says that you must pay a $90 copayment for emergency care. You received a PET scan on October 2, 2020. Therefore, you are responsible to pay the $300 copayment. You received a bronchoscopy on October 5, 2020. A bronchoscopy is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $350 copayment. You received emergency care on November 13, 2020. Therefore, you are responsible to pay the $90
copayment. The total amount you owe is: $740.
You have been asked to pay the total copayment amount of $740 for a PET scan, a bronchoscopy and emergency care. A PET scan falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. A bronchoscopy falls within the outpatient surgery, including services provided at ambulatory surgical centers and outpatient hospital facilities benefit category. Emergency care falls within the emergency 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 copayments for a PET scan, a bronchoscopy and emergency care provided from October 2, 2020, to November 13, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the placement of amniotic membrane on the ocular surface service coded 65779 provided on February 4, 2020.
You asked the Plan to pay for the placement of amniotic membrane on the ocular surface service. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.
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 65779 is placement of amniotic membrane on the ocular surface; single layer, sutured. We find that CPT code 65779 is not supported in the medical record. Specifically, this service is a duplicate service to a claim billed by the same provider for the same date of service. Based on this information, we decided that Medicare rules for coverage of the placement of amniotic membrane on the ocular surface service have not been met. Therefore, we decided that the Plan does not have to pay for the placement of amniotic membrane on the ocular surface service coded 65779 provided on February 4, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.

You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that you can continue to receive appropriate intensive rehabilitation services at the inpatient rehab facility.

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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF services.

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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the mobile x-ray services.

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 are not covered.

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with a valid POS code.

We looked at the file and Medicare rules. The file shows that the services were rendered during a non-covered skilled nursing facility (SNF) stay and should be billed with POS code 32. The claim was incorrectly billed with POS code 31. 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 mobile x-ray services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy services (HCPCS S9502) provided to the enrollee.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says this code is not valid for Medicare purposes.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.

We find that HCPCS code S9502 is not supported in the medical record. Specifically, this code has a status indicator of I according to the Medicare Physician's Fee Schedule. This indicates that the code is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy services (HCPCS S9502) provided to the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown on tooth #18 (D2740) and core buildup (D2750) for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested dental services are not considered medically reasonable and necessary in this case. Our physician reviewer found the request has been made for a buildup and crown to replace an existing crown on tooth #18. The provided x-rays reveal an endodontically treated tooth #18 with recurrent decay under the crown into the mesial root. The extent of the decay appears to approach the level of the bone, which has receded due to periodontal disease. It appears that after decay removal there would insufficient structure remaining on the mesial aspect to allow for a proper crown margin. The thickness of the dentin must be at least 1 mm at the margin to allow for the crown to properly function and seal, and after decay removal there would be either insufficient thickness with a small margin present or the decay would have encroached on the bony crest making it impossible to properly fit a crown. With either scenario, there would be no reasonable method to restore the tooth. Given the depth of the caries in the mesial root and the proximity to the bone there would not be necessity for the requested crown, or the dependent service of the core buildup.

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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve a crown on tooth #18 (D2740) and core buildup (D2750) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a full mouth series of x-rays (D0210) received on October 16, 2020.
You asked the Plan to pay for the x-rays. You say that this should be reconsidered. The Plan denied your request. The Plan says there is no coverage for this 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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a full mouth series of x-rays (D0210) received on October 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the periodontal scaling and root planing (D4341 x 4), the gingival irrigation (D4921 x 4), and the medicaments (D9630 x 2) provided on February 25, 2020.
You asked the Plan to reimburse you for the dental services. You say that the dental office advised the services would be covered. You say that you agreed to come back for an exam and cleaning. You say that you were given an estimate of $700, which you paid. You say that you only had a basic cleaning and nothing more. You also say that the provider billed for services that you did not receive. The Plan denied your request. The Plan says periodontal scaling and root planing has a 50% coinsurance. The Plan says that gingival irrigation is not listed as a covered service. The Plan also says that medicaments are not listed as covered services 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 requested items or services are not among those covered under this benefit. The Evidence of Coverage clearly states that any services not listed are not covered. Therefore, we decided that the Plan does not have to reimburse you for the periodontal scaling and root planing (D4341 x 4), the gingival irrigation (D4921 x 4), and the medicaments (D9630 x 2) provided on February 25, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a colonoscopy provided on December 2, 2020.
You asked the Plan to waive the copayment for a colonoscopy. You say that you should not owe a copayment for colonoscopy screenings. 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 $350 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. The medical records show that you had polyps removed during a colonoscopy on December 2, 2020. Therefore, the colonoscopy is considered diagnostic, not preventative, and you are responsible to pay the $350 copayment. You have been asked to pay a $350 copayment for a colonoscopy. A colonoscopy falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 colonoscopy provided on December 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the myocardial perfusion imaging provided on October 13, 2020.
You asked the Plan to waive the copayment for the myocardial perfusion imaging. You say that the provider didn't have adequate staffing to do the full visit, so you had to return the next day. You say that you shouldn't have to pay the copayment. The Plan denied your request. The Plan says the copayment 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 $40 copayment per provider, per date of service for routine radiology (x-ray, radiology, diagnostic services, ultrasounds). You have been asked to pay a $40 copayment for the myocardial perfusion imaging. The myocardial perfusion imaging 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 the myocardial perfusion imaging provided on October 13, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (80307, G0483).

You asked the Plan to pay for drug testing. You say that this is supported in the records. The Plan denied your request. The Plan says this was billed with an incorrect POS.

The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS).

We looked at the file and Medicare rules. The services at issue were billed with POS 81 for an independent laboratory, but the records indicate that the sample was not taken in a laboratory. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing (80307, G0483).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the prostate cancer mRNA gene expression testing (0047U).

You asked the Plan to waive the coinsurance for the genetic test. You say that you had this test several years ago and did not have a cost-sharing responsibility at that time. The Plan denied your request. The Plan says in 2020, genetic testing requires 20% coinsurance.

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 genetic testing.

You have been asked to pay $774.60 for a genetic test. The Plan's allowed amount for this test is $3,873 ($3,873 x 20% = $774.60). 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 the prostate cancer mRNA gene expression testing (0047U).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for medical nutrition therapy.

You asked the Plan to pay for medical nutrition therapy services. You say that because of medical conditions you need the medical nutrition therapy services. The Plan denied your request. The Plan says medical nutrition therapy is not covered for your condition.

The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services only for enrollees with renal disease or diabetes.

Records do not show that you suffer from renal disease or diabetes. Therefore, we decided that the Plan does not have to pay for medical nutrition therapy.