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

We decided that the Plan does not have to pre-approve the Freestyle Libre 14 day sensor.
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says the requested product was determined to not be reasonable or 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 monitor. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found you are only taking insulin once per day. The insulin dose is being adjusted once every five days. The elements of the coverage determination are not satisfied. 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 monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve the Freestyle Libre 14 day sensor.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a second joint survey (77077) provided on June 26, 2020.
You asked the Plan to pay for a second joint survey. You say that this should be covered. The Plan denied your request. The Plan says this exceeds the MUE for this code.
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 77077 is 1. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of a joint survey have not been met. Therefore, we decided that the Plan does not have to pay for a second joint survey (77077) provided on June 26, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve preoral esophageal myotomy (POEM).
You asked the Plan to pre-approve the POEM. You say that you would like reconsideration because this procedure is to treat swallowing disorders and hospital inpatient admission. The Plan denied your request. The Plan says the clinical value and effectiveness of POEM in the setting of Type I Achalasia has not been demonstrated in the peer-reviewed literature.
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 POEM. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review has determined that the medical necessity criteria have not been met for POEM given Type I Achalasia and the enrollee is not a participant of a clinical trial. 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 POEM have not been met. Therefore, we decided that the Plan does not have to pre-approve preoral esophageal myotomy (POEM).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory testing provided on January 8,
2021.
You asked the Plan to waive the copayment for lab tests. You say that you were told you would have no cost
for this service. The Plan denied your request. The Plan says the copayment amount you are being charged is
correct.
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
copayment for lab services at an outpatient hospital.
You have been asked to pay $20 copayment for lab tests. Lab tests fall 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 laboratory testing provided on January 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction provided on November 30, 2020 by an out of network (OON) provider.

You asked the Plan to pay for refraction. You say that you were told that no referral was needed, and you are on a fixed income. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this service is not covered when performed by an out-of-network provider.

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 an eye refraction provided on November 30, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown on tooth #7 (D2750).
You asked the Plan to pre-approve a crown on tooth #7. You say that the services are necessary. The Plan denied your request. The Plan says the benefit has been exhausted.
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 2 crowns. We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a crown on tooth #7 have not been met. Therefore, we decided that the Plan does not have to pre-approve a crown on tooth #7 (D2750).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical assistant services provided to the enrollee on
November 19, 2020.

You asked the Plan to pay for the services. You say that both codes billed are payable for the assistant surgeon.
The Plan denied your request. The Plan says registered nurse first assistants (RNFA) are not eligible to bill
Medicare for assistant surgery.

The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the
procedure is covered for an assistant and the person who assists the surgery bears the designation of a
physician, PA, NP, or CNS.

In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP,
or CNS. The provider was an RNFA. Medicare only makes payment for surgical assistant services when
provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for
surgical assistant services provided to the enrollee on November 19, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing provided to the enrollee on December 16, 2019.
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 these are invalid procedure codes for this service.
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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at issue in this case should be reported with CPT 81479. 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 Comprehensive Genomic Profile (CGP) testing provided to the enrollee on December 16, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) and shoulder orthosis (L3670) provided November 3, 2020.
You asked the Plan to pay for the lumbar-sacral orthosis and shoulder orthosis. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the initial contact was through an unsolicited phone call which is prohibited.
The Plan must follow Medicare rules. Medicare rules say that a durable medical equipment supplier is not allowed to contact the enrollee by telephone without prior permission. We looked at the file and Medicare rules. In this case, the Plan has attested that the enrollee was contacted via an unsolicited phone call regarding the provision of the item at issue. The enrollee has specifically stated that they did not previously request a call from the durable medical equipment provider. Based on this information, we decided that Medicare rules for coverage of the lumbar-sacral orthosis and shoulder orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) and shoulder orthosis (L3670) provided November 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for platelet rich plasma injection (0232T) and foot orthotics (L3000) provided August 11, 2020, to November 2, 2020.

You asked the Plan to pay for platelet rich plasma injection and foot orthotics. You say that you would like these claims reprocessed and approved for payment. The Plan denied your request. The Plan says these are not covered services.

Foot Orthotics

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition.

Platelet rich plasma injection

Medicare rules state that platelet rich plasma injections are only covered for the treatment of chronic non-healing diabetic, venous and/or pressure wounds.

In this case, the medical records do not support that the PRP injection was for the treatment of chronic non-healing diabetic, venous and/or pressure wounds. Therefore, we decided that the Plan does not have to pay for platelet rich plasma injection (0232T) and foot orthotics (L3000) provided August 11, 2020, to November 2, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Superion interspinous spacer.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that this service is considered experimental and investigational.
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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. 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. Our physician reviewer found that your condition does not meet criteria for these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Superion interspinous spacer.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that inpatient rehab is best level of care. The Plan denied your request. The Plan says that you may be equally well served at an alternative level of 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 reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for surgery to treat shortened Achilles tendon and hammertoes. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a pulmonary office visit (G8422, 1036F, G8427, 99204) provided October 21, 2020.
You asked the Plan to waive the copayment for the office visit. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct copayment was applied.
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 $20 copayment for specialist visits. You have been asked to pay a $20 copayment for the office visit. The office visit falls within the specialist visits 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 pulmonary office visit (G8422, 1036F, G8427, 99204) provided October 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a right knee brace (L1833) and a suspension sleeve (L2397) provided on September 21, 2020.
You asked the Plan to pay for a knee brace and a suspension sleeve. You say that the requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.
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 a knee brace and a suspension sleeve. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee's chief complaint was chronic pain located in the bilateral knees. The documentation in the case file does not support that the requested knee orthosis and sleeve were medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by Medicare. There is insufficient documentation of an appropriate evaluation of the enrollee, and there is insufficient credible objective documentation of joint laxity. The item coded L2397 (sleeve) is not separately payable when the base item is not covered.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a knee brace have not been met. Furthermore, the requested suspension sleeve is not separately payable when the base item is not covered. Therefore, we decided that the Plan does not have to pay for a right knee brace (L1833) and a suspension sleeve (L2397) provided on September 21, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid provided on
June 3, 2020.
You asked the Plan to pay for the infectious agent detection. You say that you would like this service to be
processed for payment. The Plan denied your request. The Plan says Original Medicare would be responsible
for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services.
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for the infectious agent detection by nucleic acid provided on
June 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited (problem-focused) oral evaluation (D0140) provided on December 7, 2020.
You asked the Plan to pay for the limited evaluation. You say that you changed dental providers and did not realize that there is a limitation on oral evaluations. The Plan denied your request. The Plan says you are only covered for one limited exam to evaluate a problem per plan year. The Plan paid for you to have this same type of evaluation on October 9, 2020. Therefore, your benefit for limited oral evaluations was exhausted on the date in question, and no payment can be made.
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 evaluation is requested in a frequency greater than what the Plan's supplemental benefit allows. Therefore, we decided that the Plan does not have to pay for the limited (problem-focused) oral evaluation (D0140) provided on December 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a primary care office visit provided on November 12, 2020.
You asked the Plan to waive the copayment for office visit. You say that you received an annual preventive visit and do not agree with this copayment. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.
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 $10 copayment for primary care office visit. This visit included non-routine diagnoses, so an office visit with applicable copayment was billed in addition to the annual wellness visit. You have been asked to pay $10 copayment for office visit. Office visit falls within the Physician/Practitioner Services, Including Doctor's Office Visits 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 primary care office visit provided on November 12, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for the ambulance services.

You asked the Plan to waive the co-payment for the ambulance services. You say that you know that your part of the bill is $150 but you are single, with no job and on disability so that's a lot of money The Plan denied your request. The Plan says you were charged this cost sharing correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 co-payment for each ambulance trip. You had 1 ambulance trip(s). The Plan charged you $150 for these 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 co-payment for the ambulance services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown - porcelain fused to high noble metal (D2750).
You asked the Plan to pay for the crown. You say that you have dental coverage, therefore the plan should pay for the claim. The Plan denied your request. The Plan says the requested service 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 - porcelain fused to high noble metal (D2750).