Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit.

You asked the Plan to waive the copayment for a specialist visit. You say that this was a phone call check-up. 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 $45 copayment for specialist visits.

You have been asked to pay a $45 copayment for a specialist visit. A specialist 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 specialist visit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the pneumatic compression device (E0651 and E0667).

You asked the Plan to pre-approve the pneumatic compression device. You say that you would like reconsideration because this equipment is medically necessary. The Plan denied your request. The Plan says the documentation received fails to indicate that the member meets the definition of lymphedema.

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 pneumatic compression device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the diagnosis of lymphedema has not been clearly established. Other modalities for leg swelling have not been tried for 4 weeks. Pneumatic compression is experimental in cases of knee pain.

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 pneumatic compression device have not been met. Therefore, we decided that the Plan does not have to pre-approve the pneumatic compression device (E0651 and E0667).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a podiatry office visit.

You asked the Plan to waive this copayment. You say that this was a follow up visit after surgery and should not be charged. The Plan denied your request. The Plan says this copayment was charged based on the claim submitted by your provider and the Plan contract agreement.

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 $40 copayment for podiatry services. Your provider billed this as an office visit. 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 podiatry office visit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a standard power wheelchair.

You asked the Plan to pre-approve a standard power wheelchair. You say that you need the requested item. The Plan denied your request. The Plan says rules for a standard power wheelchair have not been met.

The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 

The file does not contain sufficient information to determine whether you can safely operate the PMD being requested. The record shows that the Plan made several attempts to obtain the necessary documentation without success. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a standard power wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the lower extremity addition (L5652).

You asked the Plan to pre-approve the lower extremity addition.. You say that you would like reconsideration because this equipment is medically necessary. The Plan denied your request. The Plan says the separate suspension system cannot be used with the approved suspension system.

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 lower extremity addition. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found The L5652 appears to exceed the member's medical need as the member was already approved for a L5671 below/above knee suspension locking mechanism. The documentation does not reveal that the member's medical needs and function cannot be met with the L5671 suspension mechanism.

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 lower extremity addition. have not been met. Therefore, we decided that the Plan does not have to pre-approve the lower extremity addition (L5652).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an oral device or appliance to reduce airway collapsibility (E0486).

You asked the Plan to waive the coinsurance for an oral device or appliance. You say that you were advised that the requested item/service would be completely covered by the Plan. The Plan denied your request. The Plan says the correct coinsurance 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 20% coinsurance for covered items of durable medical equipment and related supplies.

You have been asked to pay $850.00, or 20% of the Medicare-allowed amount of $4,250.00, for an oral device or appliance to reduce airway collapsibility. An oral device or appliance to reduce airway collapsibility falls within the "Durable medical equipment (DME) and related 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 coinsurance for an oral device or appliance to reduce airway collapsibility (E0486).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit.

You asked the Plan to pay for the services provided. You say that the bill with the proper diagnosis codes was submitted. The Plan denied your request. The Plan says Medicare will not pay for services from a provider that is not eligible to participate in Medicare.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that if you go to a provider who is not eligible to participate in Medicare, you will be responsible for the full cost of the services you receive.

The provider in this case is not a network provider with the Plan, or eligible to provide services under Original Medicare. 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 the office visit.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the coinsurance for the chemotherapy services.

You asked the Plan to waive the coinsurance for the chemotherapy services. You say that you were not made aware of the change in benefit. The Plan denied your request. The Plan says that you have been asked to pay the correct cost-sharing amount.

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.

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 submit the allowed amounts on the Explanations of Benefits. This means we are unable to determine if the coinsurance amounts you are being asked to pay are correct. Therefore, we decided that the Plan has to waive the coinsurance for the chemotherapy services.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140), the upper denture adjustment (D5410), and the lower denture adjustment (D5411).

You asked the Plan to pay for the dental services. You say that you were not aware that denture adjustments were only covered one time per year. You say that you received a postcard from your dental office advising you to come in to not lose your benefits. You say that this is the only reason you went in. You also say that you were under the impression that you had a second adjustment. The Plan denied your request. The Plan says 1 limited oral evaluation is covered every 6 months. The Plan says that denture adjustments are covered once per year, per arch. The Plan also says that the 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 and the services are listed as covered, the frequency limits have been exceeded. The record shows that the Plan paid for a limited oral evaluation, an upper denture adjustment, and a lower denture adjustment. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140), the upper denture adjustment (D5410), and the lower denture adjustment (D5411).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the digital breast tomosynthesis rendered.

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 procedure code 77061 is not covered.

The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid for Medicare purposes.

We looked at the file and Medicare rules. Billed procedure code 77061 (digital breast tomosynthesis) has a status indicator of I and is not valid for Medicare purposes. Therefore, we decided that the Plan does not have to pay for the digital breast tomosynthesis rendered.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the complete denture - mandibular (D5120).

You asked the Plan to pre-approve the complete denture - mandibular. You say that you need the dentures. The Plan denied your request. The Plan says you have met your frequency limit.

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 complete denture - mandibular once every 5 years. 

We looked at the file and Medicare rules. The Plan has already previously covered denture services in the past 5 years. Based on this information, we decided that the Plan's rules for coverage of the complete denture - mandibular have not been met. Therefore, we decided that the Plan does not have to pre-approve the complete denture - mandibular (D5120).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment charged for ambulance transport.

You asked the Plan to waive this copayment. You say that you do not believe this copayment is correct. The
Plan denied your request. The Plan says this copayment was charged based on the services provided and the
Plan contract agreement.

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 $250
copayment for each one-way ambulance transport. 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 charged for ambulance
transport.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397).

You asked the Plan to pay for the knee orthosis and suspension sleeve. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the enrollee received an unsolicited phone call from the durable medical equipment provider.

The Plan must follow Medicare rules. Medicare rules say that coverage is not available when the durable medical equipment makes an unsolicited phone call without permission to the enrollee.

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. Based on this information, we decided that Medicare rules for coverage of the knee orthosis and suspension sleeve have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an excision procedure for excessive thigh skin.

You asked the Plan to pre-approve the requested services. You say that the excess skin causes skin infections and strain on your knees. The Plan denied your request. The Plan says the request is cosmetic in nature.

The Plan follows Medicare rules. Medicare rules say that surgery to correct congenital defects, developmental abnormalities, trauma, infections, tumors, or disease may be covered when the surgery is considered reconstructive in nature.

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 you underwent Bariatric surgery and are being evaluated for body contouring. In this case, there are no medical records supporting the allegation of Intertrigo, infection or irritation of the thigh skin. The photographs do not support these claims either. Therefore, the requested procedure is 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 an excision procedure for excessive thigh skin.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services 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 the procedures codes are not correct or valid.

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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee had hypothyroidism and hyperlipidemia who underwent testing with an expanded pharmacogenomic panel. The request is for coverage of these services. In this case the documentation provided indicates a conclusory statement that the service ordered does not address the medical necessity or reasonableness of the requested service.

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 pay for laboratory services provided to the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services.

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, these services should
be billed with code 81479. In addition, the appropriate DEX Z code identifier should be entered adjacent in the
comment/narrative field. 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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a soft occlusal guard (D9945) to wear at night.

You asked the Plan to pre-approve the occlusal guard. You say that this item is medically necessary for you, and you feel the Plan should make an exception as you still have money left in your benefit allowance. The Plan denied your request. The Plan says dental guards are not covered by Medicare or by the Plan's supplemental dental 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 pre-approve a soft occlusal guard (D9945) to wear at night.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.

You asked the Plan to pre-approve foot orthotics. You say that you have the same chronic foot problems as a diabetic. The Plan denied your request. The Plan says this item is not a covered benefit.

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. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) and endodontic therapy (D3310) to be provided by an Endodontist.

You asked the Plan to pre-approve dental services provided by an Endodontist. You say that these services should be covered as they are medically necessary. The Plan denied your request. The Plan says Endodontic therapy is not covered by Medicare or by the Plan's supplemental dental benefit. A comprehensive evaluation is eligible for coverage under the Plan's supplemental benefit, however dental services can only be covered when they are performed by a participating general dentist. Care provided by an Endodontist is not covered.

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, endodontic therapy is not among those covered under this benefit in any circumstance, and the comprehensive evaluation cannot be covered as it will be provided by a professional other than a general dentist. The Plan's rules have not been met. Therefore, we decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) and endodontic therapy (D3310) to be provided by an Endodontist.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the closed treatment of hip dislocation services coded 27250.

You asked the Plan to pay for the closed treatment of hip dislocation 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. 

In this case, the CPT Code Manual definition of code 27250 is closed treatment of hip dislocation, traumatic; without anesthesia.

We find that CPT code 27250 is not supported in the medical record. Specifically, this code was billed with modifiers 54 and LT. Physicians who furnish part of a global surgical package where physicians agree on the transfer of care during the global period, modifier 54 is used for surgical care only for postoperative management only. Both the bill for the surgical care only and the bill for the postoperative care only, will contain the same date of service and the same surgical procedure code, with the services distinguished by the use of the appropriate modifier. Providers need not specify on the claim that care has been transferred. However, the date on which care was relinquished or assumed, as applicable, must be shown on the claim. This should be indicated in the remarks field/free text segment on the claim form/format. Both the surgeon and the physician providing the postoperative care must keep a copy of the written transfer agreement in the beneficiary's medical record. The code was not billed with the appropriate modifier. Based on this information, we decided that Medicare rules for coverage of the closed treatment of hip dislocation services have not been met. Therefore, we decided that the Plan does not have to pay for the closed treatment of hip dislocation services coded 27250.