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

We decided that the Plan does not have to waive the copayment for wound care provided by a participating provider on August 10, 2020, to August 17, 2020.
You asked the Plan to waive the copayment for wound care. You say that you do not agree with these charges. The Plan denied your request. The Plan says the correct copayment has been 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 $350 copayment for outpatient surgery/outpatient hospital facility. You have been asked to pay a $350 copayment for wound care. The total amount you are being asked to pay is $478.75 ($350 + $128.75 = $478.75) which is less than your copayment amount of $700 ($350 x 2 surgeries = $700). Wound care falls within the outpatient surgery/outpatient hospital facility 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 wound care provided by a participating provider on August 10, 2020, to August 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oxygen concentrator provided from September 30, 2019, 
through  
December 30, 2019. 
 
You asked the Plan to pay for the oxygen concentrator. The Plan denied your request. The Plan says the Plan 
requires utilization of network providers when possible and available and requires authorization for certain 
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has 
been documented. 
 
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 
oxygen concentrator. We found no exception that would require the Plan to pay for this item. Therefore, we 
decided that the Plan does not have to pay for an oxygen concentrator provided from September 30, 2019, 
through December 30, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe periodontal scaling and root planing(D4341 x 2), gingival irrigation (D4921 x 2), and the localized delivery of microbial agents (D4381 x 6) provided on September 23, 2020.You asked the Plan to pay forthe dental services. You say that you feel the financial representative and the dentist were very misleading and shared incorrect information. You say that you have paid almost $2,000 out of pocket for the services so far and cannot afford to pay anymore.The Plan denied your request. The Plan says periodontal scaling and root planing is covered with a 30% coinsurance when you receive this service in network. The Plan says gingival irrigation is not listed as a covered service. The Plan also says that localized delivery of microbial agents is not listed as a covered service.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the periodontal scaling and root planing was processed correctly. The record shows that the Plan paid the 30% coinsurance towards these services. Additionally, the gingival irrigation and the localized delivery of microbial agents are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe periodontal scaling and root planing (D4341 x 2), gingival irrigation (D4921 x 2), and the localized delivery of microbial agents (D4381 x 6) provided on September 23, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lead wires rendered on September 3, 2020. 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. The rules say that replacement of lead wires (A4557) more often than every 12 months would rarely be reasonable and necessary. We looked at the file and Medicare rules. The file shows that the TENS device was rendered on July 3, 2020. Replacement lead wires more often than every 12 months is not necessary. Therefore, we decided that the Plan does not have to pay for the lead wires rendered on September 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on September 18, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
physician?s services. We found no exception that would require the Plan to pay for these services. Therefore, 
we decided that the Plan does not have to pay for physician's services provided on September 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical placement of implant body (D6010), therapeutic enteral drugs (D9612), intravenous moderate sedation, first 15 minutes (D9239), intravenous moderate sedation, each subsequent 15 minutes (D9243), and one panoramic x-ray (D0330) provided on May 21, 2020 and June 15, 2020.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says these services are not covered benefit under your contractual policy. Additionally, you have exhausted the benefit allowance for coverage of one additional panoramic x-ray provided.
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 services provided are not among those covered under this benefit. Additionally, your request for coverage of an additional panoramic x-ray provided exceeds the allowable benefit for this service. The Plan contract allows for payment of one panoramic x-ray every thirty six months. Two panoramic x-rays were provided on June 15, 2020. The Plan processed the claim for payment of one panoramic x-ray. Therefore, we decided that the Plan does not have to pay for the surgical placement of implant body (D6010), therapeutic enteral drugs (D9612), intravenous moderate sedation, first 15 minutes (D9239), intravenous moderate sedation, each subsequent 15 minutes (D9243), and one panoramic x-ray (D0330) provided on May 21, 2020 and June 15, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab work provided on September 29, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and paid. The Plan 
denied your request. The Plan says prior authorization was not obtained. The Plan says that the member's 
primary care physician did not refer these services. 
 
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 lab work provided on September 29, 2020 by an 
out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forTENS lead wires A4557 provided to the enrollee on September 29, 2020.You asked the Plan to pay forthe TENS lead wires. You say that A4557 is not inclusive to A4595 and want the claim reprocessed for payment.The Plan denied your request. The Plan says the code for A4557 is for replacement wires, and it has not been twelve months since the TENS device, E0730(a Transcutaneous electrical nerve stimulation (tens) device, four or more leads, for multiple nerve stimulation) was received so it is denied.The Plan must follow Medicare rules. Medicare rules say that 'Replacement of lead wires more often than every 12 months would rarely be reasonable and necessary'. Since a TENS unit has been purchased in the previous 12 months, the lead wires have been denied. Records supporting the medical necessity of the additional lead wires were not submitted.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the TENS lead wires have not been met.Therefore, we decided that the Plan does not have to pay forTENS lead wires A4557 provided to the enrollee on September 29, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the toe amputation service (28820) provided on July 17, 2020. You asked the Plan to pay for the toe amputation. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the service 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 28820 is amputation, toe; metatarsophalangeal joint. We asked our coder 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 toe amputation. Our reviewer says that CPT code 28820 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided do not include sufficient information to validate these services were performed on July 17, 2020. No procedure description is included in the submitted medical documentation to corroborate these services. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the toe amputation have not been met. Therefore, we decided that the Plan does not have to pay for the toe amputation service (28820) provided on July 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided by an out of network provider
on August 24, 2020.
You asked the Plan to pay for the dental services. You say that you would like the Plan to reconsider their
denial of payment. The Plan denied your request. The Plan says the dental provider is not contracted with the
Plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the dental services provided are not
among those covered under this benefit when provided by an out of network provider. Therefore, we decided
that the Plan does not have to pay for the dental services provided by an out of network provider on August 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services received on March 19, 2020. 
 
You asked the Plan to pay for the dental services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services received are not a covered benefit. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for the dental services received on 
March 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve44 fractions of proton beam radiation therapy.You asked the Plan to pre-approve44 fractions of proton beam radiation therapy. You say that the requested 44 fractions of proton beam radiation therapy is medically necessary.The Plan denied your request. The Plan says the requested 44 fractions of proton beam radiation therapy 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 44 fractions of proton beam radiation therapy. Our reviewer says that the requested 44 fractions of proton beam radiation therapy is not medically necessary. Our physician reviewer found to date, there are no compelling data to suggest that proton therapy is superior to or more beneficial than IMRT/IGRT. The generally accepted standard of care for prostate cancer is to only offer proton beam therapy on clinical trials, and to notroutinely offer it to patients.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 44 fractions of proton beam radiation therapy have not been met.Therefore, wedecided that the Plan does not have to pre-approve44 fractions of proton beam radiation therapy.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the removal of support implant billed with CPT code 20680
provided on August 4, 2020.
You asked the Plan to pay for CPT code 20680. You say that the medical records support the billing of CPT
code 20680. The Plan denied your request. The Plan says the medical records do not support the billing of CPT
code 20680.
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 20680 is Removal of implant; deep (eg, buried wire, pin,
screw, metal band, nail, rod or plate).
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 CPT code 20680. Our reviewer says that the
medical records do not support the billing of CPT code 20680. Our physician reviewer found CPT 20680 is not
supported in the medical records. The Op note does not document removal of deep implant.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of CPT code 20680 have not been met. Therefore, we decided that the Plan does
not have to pay for the removal of support implant billed with CPT code 20680 provided on August 4, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the partial toe phalanx excision surgery 
(28124) provided on August 27, 2020. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 $250 
copayment for Medicare-covered surgery or other services provided at an ambulatory surgical center or 
outpatient hospital facility, including but not limited to hospital or other facility charges and physician or 
surgical charges. 
 
You have been asked to pay a $250 copayment for the Medicare-covered surgery provided at an ambulatory 
surgical center. 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 partial toe phalanx excision surgery 
(28124) provided on August 27, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (G0483) provided July 29, 2020.
You asked the Plan to pay for the lab 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 G0483 is Drug test(s), definitive, 22 or more drug class(es), including metabolite(s) if performed. We find that CPT code G0483 is not supported in the medical record. Specifically, the record does not show 22 or more drug classes were tested for. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (G0483) provided July 29, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for a second duplex scan interpretation provided on September 
21, 2018. 
 
You asked the Plan to pay for a second duplex scan interpretation. You say that the Plan should pay this claim. 
The Plan denied your request. The Plan says the record shows one duplex scan interpretation was done. 
 
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 93971 is duplex scan of extremity veins including 
responses to compression and other maneuvers; unilateral or limited study. 
 
We find that a second CPT code 93971 interpretation is not supported in the medical record. Specifically, the 
medical notes submitted support one interpretation. Based on this information, we decided that Medicare rules 
for coverage of a second duplex scan interpretation have not been met. Therefore, we decided that the Plan 
does not have to pay for a second duplex scan interpretation provided on September 21, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveextra depth diabetic shoes with three pairs of inserts.You asked the Plan to pre-approvethe diabetic shoes and inserts. You say that the claim should be approved.The Plan denied your request. The Plan says the medical records included with the request do not document any history of previousfoot ulceration, history of pre-ulcerative calluses, or peripheral neuropathy, a foot deformity or poor circulation.
The Plan follows Medicare rules. Medicare rules say that to qualify for coverage for diabetic shoes or inserts, the enrollee must have diabetes mellitus and have documented history of previous foot ulceration, history of pre-ulcerative calluses, peripheral neuropathy, or a foot deformity or poor circulation.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 diabetic shoes and inserts. Our reviewer says that the service is not medically necessary. Our physician reviewer found while the enrollee has diabetes mellitus, there is no history of previous foot ulceration, history of pre-ulcerative calluses, or peripheral neuropathy, a foot deformity or poor circulation.We looked at this physician's review, the file, and Medicare rules. Based on this information, wedecided that Medicare rules for coverage of the diabetic shoes and inserts have not been met.Therefore, we decided that the Plan does not have to pre-approveextra depth diabetic shoes with three pairs of inserts
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiology services provided on June 3, 2020 by an out of 
network provider. 
 
You asked the Plan to pay for noninvasive physiologic studies (93922) and duplex scan (93925). You say that 
the Plan should pay this claim. The Plan denied your request. The Plan says you did not obtain prior 
authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan 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 the radiology services provided on June 3, 2020 
by an out of network provider.