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

We decided that the Plan does not have to issue reimbursement for the warranty (A9999) purchased on
June 26, 2020.
You asked the Plan to issue reimbursement. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says this item is not a covered benefit under your contractual policy or by Medicare.
The Plan must follow Medicare rules. Medicare rules say that DME is defined as equipment which: Can withstand repeated use; i.e., could normally be rented, and used by successive patients; Is primarily and customarily used to serve a medical purpose; Generally, is not useful to a person in the absence of illness or injury and; Is appropriate for use in a patient's home.
The item at issue in this appeal does not meet Medicare criteria for coverage. Medicare provides coverage for items which meet the definition of DME. The warranty you purchased does not fall within the definition of DME but is something you elected to purchase to cover issues with the item. This does not fall into any Medicare benefit category. Therefore, we decided that the Plan does not have to issue reimbursement for the warranty (A9999) purchased on June 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam CT image capture with field of view of one full dental arch, two preventive procedures, endodontic therapy of an anterior tooth, and endodontic therapy of a premolar tooth provided on January 6, 2021, and January 21, 2021.

You asked the Plan to pay for the cone beam CT image capture, preventive procedures, and endodontic therapies. You say that you were advised that root canals were covered. The Plan denied your request. The Plan says these services are 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, the requested items or services are not
among those covered under this benefit. The record shows that you contacted the Plan on January 4, 2021 and
were given the name of a participating provider. The record also shows that you did not receive any benefit or
coverage information during this call. Therefore, we decided that the Plan does not have to pay for the cone
beam CT image capture with field of view of one full dental arch, two preventive procedures, endodontic
therapy of an anterior tooth, and endodontic therapy of a premolar tooth provided on January 6, 2021, and
January 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series of intraoral x-rays provided on February 25, 2021.
You asked the Plan to pay for the complete series of intraoral x-rays. You say that you would like this claim to be reconsidered for coverage. The Plan denied your request. The Plan says this service is not a covered benefit. The Plan also says that there were no calls from you or your provider prior to this date of service requesting covered dental benefits.
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 complete series of intraoral x-rays provided on February 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on August 7, 2020.
You asked the Plan to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device. You say that the treatment was medically necessary and should be covered. The Plan denied your request. The Plan says the record does not support that the procedures were performed as 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 HCPCS/CPT Code Manual definition of code 97016 is application of blood vessel compression or decompression device to 1 or more areas. The HCPCS/CPT Code Manual definition of code 97032 is application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes. The HCPCS/CPT Code Manual definition of code 97150 is therapeutic procedure(s), group (2 or more individuals). The HCPCS/CPT Code Manual definition of code 96372 is therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular. The HCPCS/CPT Code Manual definition of code J3490 is unclassified drug injection. The HCPCS/CPT Code Manual definition of code J3411 is injection, thiamine hcl, 100 mg. The HCPCS/CPT Code Manual definition of code J3415 is injection, pyridoxine hcl, 100 mg.
We decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on August 7, 2020.
You asked the Plan to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device. You say that the treatment was medically necessary and should be covered. The Plan denied your request. The Plan says the record does not support that the procedures were performed as 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 HCPCS/CPT Code Manual definition of code 97016 is application of blood vessel compression or decompression device to 1 or more areas. The HCPCS/CPT Code Manual definition of code 97032 is application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes. The HCPCS/CPT Code Manual definition of code 97150 is therapeutic procedure(s), group (2 or more individuals). The HCPCS/CPT Code Manual definition of code 96372 is therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular. The HCPCS/CPT Code Manual definition of code J3490 is unclassified drug injection. The HCPCS/CPT Code Manual definition of code J3411 is injection, thiamine hcl, 100 mg. The HCPCS/CPT Code Manual definition of code J3415 is injection, pyridoxine hcl, 100 mg.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an office visit provided on March 8, 2021.
You asked the Plan to waive the deductible for an office visit. You say that you do not agree with this deductible. The Plan denied your request. The Plan says the correct deductible amount has been applied.
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 a $198 deductible for certain services.
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $198 deductible for certain services. The total amount you are being asked to pay is $114.56. This cost sharing is a contractual obligation that had not been met at the time an office visit was received on March 8, 2021. Therefore, we decided that the Plan does not have to waive the deductible for an office visit provided on March 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a shoulder-arm orthosis (L3960) provided on November 30, 2020.
You asked the Plan to pay for a shoulder-arm orthosis. You say that the requested item was a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for durable medical equipment have not been met.
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 relevant medical records which support medical necessity for the supplies provided in this case. 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 a shoulder-arm orthosis (L3960) provided on November 30, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation (A0427
A0425) received June 7, 2020.
You asked the Plan to waive the copayment for the ambulance transportation. You say that the Plan should pay
this claim. The Plan denied your request. The Plan says the correct cost share applied to the claim.
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 $225
copayment for each one-way Medicare-covered ground trip.
You have been asked to pay a $225 copayment for the ambulance transportation. This service is considered a
one-way Medicare-covered ground trip. 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
ambulance transportation (A0427 A0425) received June 7, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care services provided on January 14, 2021, through January 18, 2021.
You asked the Plan to waive the copayment for emergency care services. You say that the services should be covered. The Plan denied your request. The Plan says the cost share was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $120 emergency services copayment for outpatient hospital services. You have been asked to pay a $120 emergency services copayment for emergency care services. This service falls within the outpatient hospital 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 emergency care services provided on January 14, 2021, through January 18, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional ten (10) acupuncture treatments.
You asked the Plan to pre-approve an additional ten (10) acupuncture treatments. You say that you believe it is medically necessary for knee arthritis and your anxiety and pain. You say that after your treatments you leave with no pain. The Plan denied your request. The Plan says while Medicare recently started covering acupuncture for low back pain, it is not covered if the member is not showing improvements. In this case, you have been going for treatments but have not been improving.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case.
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 an additional ten (10) acupuncture treatments. Our reviewer says that additional acupuncture treatments are not medically necessary. Our physician reviewer found that the criteria for additional acupuncture and requested services have not been met per the Medicare National Coverage Determinations Manual, Section 30.3.3. The documentation does not reveal significant objective functional improvement from prior acupuncture therefore additional acupuncture is not medically necessary for your condition. 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an additional ten (10) acupuncture treatments have not been met. Therefore, we decided that the Plan does not have to pre-approve an additional ten (10) acupuncture treatments.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on October 27, 2020.

You asked the Plan to pay for the ambulance services. You say that you did not request for this service. The Plan denied your request. The Plan says these services are not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. 

The ambulance company did not provide transport services on October 27, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on October 27, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan of the abdomen/pelvis rendered on January 11, 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 claim is a duplicate.
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the Plan on a separate claim for the same date of service. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan of the abdomen/pelvis rendered on January 11, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an MRI scan of thoracic spine (72157), of the cervical spine (72156), and of the brain (including brain stem) (70553) provided on August 13, 2020, by an out of network provider.
You asked the Plan to pay for an MRI scan of thoracic spine, of the cervical spine, and of the brain. You say that the requested services were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for out of network care have not been met.
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 MRI scan of thoracic spine (72157), of the cervical spine (72156), and of the brain (including brain stem) (70553) provided on August 13, 2020, by an out of network provider
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on July 13, 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 testing is not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. 
The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on July 13, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a LAAC with Watchman procedure.
You asked the Plan to pre-approve a LAAC with Watchman. You say that the enrollee is not a good candidate for long-term anticoagulation. The Plan denied your request. The Plan says there is no documentation of the failure of a blood thinner medication.
The Plan follows Medicare rules. Medicare rules say that, for coverage of percutaneous LAAC, the enrollee must be deemed unable to take long-term oral anticoagulation. 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 a LAAC with Watchman. Our reviewer says that the requested procedure is not medically necessary. Our physician reviewer found that the medical record indicates that the enrollee has atrial fibrillation with a CHA2DS-VASc score of 4. The medical record does not indicate that the enrollee is unable to take long-term anticoagulation. The record indicates the desire to not use anticoagulation is due to cost. The elements of the coverage criteria 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 a LAAC with Watchman have not been met. Therefore, we decided that the Plan does not have to pre-approve a LAAC with Watchman procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for the specialist services rendered on November 9, 2020.

You asked the Plan to waive the co-payment for these services. You say that you went to the office at the doctor's request. The Plan denied your request. The Plan says the co-payment was applied 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 $50 co-payment for each specialist visit for Medicare-covered services.

Review of the file shows that you received specialist services on November 9, 2020. The records show that you received an exam for abdominal pain. You have been asked to pay a $50 co-payment for these services. These services fall within the specialist visit for Medicare-covered 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 co-payment for the specialist services rendered on November 9, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic exercises (97110) provided on February 10, 2020.
You asked the Plan to pay for therapeutic exercises. You say that this should be covered. The Plan denied your request. The Plan says this was not billed correctly.
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 97110 is therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility. We find that CPT code 97110 is not supported in the medical record. Specifically, the records show that this service was provided in a home health setting. There is a more appropriate code for this service.
Based on this information, we decided that Medicare rules for coverage of therapeutic exercises have not been met. Therefore, we decided that the Plan does not have to pay for therapeutic exercises (97110) provided on February 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care on March 16, 2021.
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 claim was not billed correctly.
The Plan must follow Medicare rules. The rules say that modifier "-58" was established to facilitate billing of staged or related surgical procedures done during the postoperative period of the first procedure. We looked at the file and Medicare rules. The file shows that the services were rendered within the 0 day global surgical period for procedure 11043 (muscle debridement) and were not billed with the required -58 modifier. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care on March 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on February 11, 2021 by an out of network (OON) provider.
You asked the Plan to pay for an office visit. You say that prior authorization was not obtained for these services. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician. The Plan says that there are in-network providers are available for 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 an office visit provided on February 11, 2021 by an out of network (OON) provider.