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

We decided that the Plan does not have to pay for the cardiovascular risk assessment test provided on.

You asked the Plan to pay for the cardiovascular risk assessment test. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. Cardiovascular risk assessment panels are only covered for certain indications.

Review of the file shows that the plan uses Local Coverage Determination (LCD) L36139 and L36523 to support their denial. However, LCD L36139 and L36523 is not valid for the provider's billing state of Arkansas. Therefore, we are unable to use LCD L36139 and L36523 to substantiate our decision. 

While cardiovascular risk assessment panels are covered for certain indications, the file does not support that the enrollee met criteria for these services. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment test provided on
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the diabetic shoe fitting and inserts provided on August 10, 2020.
You asked the Plan to waive the coinsurance for the diabetic shoe fitting and inserts. You say that no cost-share should have been applied. You say the service was provided in the office, but DME requires a place of service (POS) of 12. The Plan denied your request. The Plan says you have been asked to pay 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). The enrollee's contract with the Plan clearly says that enrollees must pay 20% coinsurance for in-network Medicare-covered benefits.
The enrollee has been asked to pay $19.21 which is 20% of the allowed amount for the diabetic shoe fitting. ($96.04 x 20% = $19.21). You have been asked to pay $35.06 which is 20% of the allowed amount for the inserts. ($175.32 x 20% = $35.06) ($19.21 + $35.06 = $54.2). The diabetic shoe fitting and inserts fall within the "Durable Medical Equipment (DME) and Related Supplies" benefit category.
This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the diabetic shoe fitting and inserts provided on August 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the oxygen concentrator and portable oxygen concentrator rendered on July 22, 2020 to August 22, 2020.
You asked the Plan to waive the cost sharing for these services. You say that your out-of-pocket was met and the services should be covered. The Plan denied your request. The Plan says the cost sharing was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is $250 combined in-network and out-of-network deductible for your covered medical services and a 20% coinsurance for Medicare-covered durable medical equipment and related supplies.
Review of the file shows that you received an oxygen concentrator and portable oxygen concentrator on July 22, 2020. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $250 combined in-network and out-of-network deductible for your covered medical services. This cost sharing is a contractual obligation that had not been met at the time these services were received on July 22, 2020. The Plan applied $110.24 towards your deductible for these services. At this time, your deductible was met. Given that the deductible charges did not cover the entire cost of the services, you have also been asked to pay a 20% coinsurance of the remaining amount, for a total of $6.52.
The file shows that you received an oxygen concentrator and portable oxygen concentrator on August 22, 2020. You have been asked to pay a 20% coinsurance for these services, for a total of $15.53. These services fall within the Medicare-covered durable medical equipment and related supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.
The total amount you have been asked to pay for these services is $132.29. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. The file shows that you met your out-of-pocket maximum after the processing of this claim.
Therefore, we decided that the Plan does not have to waive the cost sharing for the oxygen concentrator and portable oxygen concentrator rendered on July 22, 2020 to August 22, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for pathology services (85060) provided November 13, 2020.

You asked the Plan to pay for the pathology services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services billed.

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 85060 is not supported in the medical record. Specifically, the claim included an invalid Place of Service (22, outpatient hospital) for the CPT code billed. Based on this information, we decided that Medicare rules for coverage of the pathology services have not been met. Therefore, we decided that the Plan does not have to pay for pathology services (85060) provided November 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for orthoses (L1851, L2397) provided June 19, 2020

You asked the Plan to pay for the orthoses. You say that the services were medically necessary. The Plan
denied your request. The Plan says the documentation does not support the services billed.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.

The record does not contain a valid proof of delivery. No itemized shipping invoice was provided. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for orthoses (L1851, L2397) provided June 19, 2020
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a colonoscopy (45380) provided February 4, 2021.
You asked the Plan to waive the copayment for the colonoscopy. You say that the colonoscopy should be considered a screening service and the copayment should be waived. The Plan denied your request. The Plan says the colonoscopy included a biopsy and therefore was not a screening service. 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 $275 copayment for outpatient surgical services. You have been asked to pay a $275 copayment for the colonoscopy. the colonoscopy falls within the outpatient surgical services 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 (45380) provided February 4, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening.
You asked the Plan to pre-approve the requested LDCT scan. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested services.
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung cancer screening for enrollees who meet all the above described criteria.
We reviewed the file and the Medicare rules. We find that the enrollee does not have the absence of signs/symptoms of lung cancer. Therefore, we decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for sedation services (99152) provided October 20, 2020.
You asked the Plan to pay for the sedation services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services billed.
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 99152 is Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist.
We find that CPT code 99152 is not supported in the medical record. Specifically, the records do not show that a trained observer was present to assist. Based on this information, we decided that Medicare rules for coverage of the sedation services have not been met. Therefore, we decided that the Plan does not have to pay for sedation services (99152) provided October 20, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient admission provided November 29, 2020, to December 1, 2020.

You asked the Plan to waive the copayment for the inpatient admission. You say that you should not owe the $580 copayment. The Plan denied your request. The Plan says you have been asked to pay 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 $290 copayment for each day for days 1 to 5 for Medicare-covered hospital care and $0 copayment for additional Medicare-covered days; each emergency room visit.

You have been asked to pay a $290 copayment for each day of the inpatient admission. ($290 x 2 days = $580). The inpatient admission falls within the "Inpatient hospital care" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient admission provided from November 29, 2020, to December 1, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endoscopic discectomy.
You asked the Plan to pre-approve endoscopic discectomy. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services requested are 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 endoscopic discectomy. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support adequate conservative measures for low back pain. Also, endoscopic discectomy remains experimental. More research is needed to show safety and efficacy. Therefore, the enrollee does not meet criteria for the requested services. Review of the file shows that the plan uses Local Coverage Article (LCA) A57654 to support their denial. However, LCA A57654 is not valid for the enrollee's home state of Michigan. Therefore, we are unable to use LCA A57654 to substantiate our decision.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of endoscopic discectomy have not been met. Therefore, we decided that the Plan does not have to pre-approve endoscopic discectomy.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care provided on November 13, 2020.
You asked the Plan to pay for the subsequent hospital care. You say that the enrollee was not enrolled in hospice on this date of service. 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. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on November 11, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care provided on November 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower denture (D5120).
You asked the Plan to pre-approve the dental services. You say that you are getting bad headaches and you are not able to eat food. You say that your mouth is always sore, and you are losing a lot of weight. You say that it is also impacting your ability to speak clearly. You also say that you cannot wait 5 years to get another set. The Plan denied your request. The Plan says dentures are covered once every 5 plan years. The Plan also says that the frequency limit has been reached.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage and dentures are listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for dentures that you received on May 16, 2021. Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower denture (D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a custom fabricated abutment (D6057) and an abutment supported crown (D6058) for tooth #7.
You asked the Plan to pre-approve the abutment and crown. You say that you were told that the implant could not be covered but the crown could be covered. You are now finding that nothing is covered and feel you were given incorrect information. The Plan denied your request. The Plan says the crown and core buildup for your other tooth has been approved as requested, however custom fabricated abutments and abutment-supported crowns are not covered by the Plan's dental benefit under any circumstances.
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 pre-approve a custom fabricated abutment (D6057) and an abutment supported crown (D6058) for tooth #7.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) received November 24, 2020.
You asked the Plan to pay for the extraction. You say that you were in pain, and the extraction was necessary. The Plan denied your request. The Plan says your supplemental benefit does not cover surgical extractions.
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 extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) received November 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction (92015) provided on January 22, 2021.
You asked the Plan to pay for an eye refraction. You say that you want the Plan to pay for the service at issue. The Plan denied your request. The Plan says an eye refraction is only covered when it is performed as part of a routine examination.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when it is performed as part of a routine eye examination. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of an eye refraction have not been met. Specifically, the record indicates you received a diabetic eye examination. Therefore, the service at issue is not a covered benefit. Therefore, we decided that the Plan does not have to pay for an eye refraction (92015) provided on January 22, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on May 14, 2020.
You asked the Plan to pay for the laboratory services. 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. We find that the laboratory services are not supported in the medical record. Specifically, if a laboratory assays two or more genes in an enrollee in parallel, then those two or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so only one code must be submitted for the panel. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on May 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing provided on April 30, 2020 to June 25, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the drug testing. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.

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 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 drug testing provided on April 30, 2020 to June 25, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drug provided on November 30, 2020.
You asked the Plan to pay for the self-administered drug. You say that you feel this drug should be covered. The Plan denied your request. The Plan says this service is not a benefit under your plan.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested 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 drug provided on November 30, 2020.
Benefits for the self-administered drug 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 pay for the pharyngolaryngectomy services coded 31395 provided on October 12, 2020.
You asked the Plan to pay for the pharyngolaryngectomy services. 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 supported by the documentation.
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 31395 is pharyngolaryngectomy, with radical neck dissection; with reconstruction.
We find that CPT code 31395 is not supported in the medical record. Specifically, the operative report did not include documentation of a pharyngolaryngectomy with radical neck dissection with reconstruction; therefore this code cannot be verified. Based on this information, we decided that Medicare rules for coverage of the pharyngolaryngectomy services have not been met. Therefore, we decided that the Plan does not have to pay for the pharyngolaryngectomy services coded 31395 provided on October 12, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services (99291) provided October 21, 2020.
You asked the Plan to pay for the critical care services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services billed.
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 99291 is critical care visit of 30-74 minutes. We find that CPT code 99291 is not supported in the medical record. Specifically, the documentation does not detail how much time was spent on the critical care service. Based on this information, we decided that Medicare rules for coverage of the critical care services have not been met. Therefore, we decided that the Plan does not have to pay for critical care services (99291) provided October 21, 2020.