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

We decided that the Plan does not have to pay for surgical preparation (15004) provided on December 4, 2019.
You asked the Plan to pay for the surgical preparation. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the operative report did not include documentation of a surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture of the face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; first 100sq cm or 1% of body area of infants and children; therefore this code cannot be verified.
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 15004 is surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; first 100 sq cm or 1% of body area of infants and children 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 surgical preparation. Our reviewer says that CPT code 15004 does not meet criteria for billing or reimbursement consideration. Our reviewer found the documentation submitted does not support the service billed. 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 surgical preparation have not been met. Therefore, we decided that the Plan does not have to pay for surgical preparation (15004) provided on December 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on January 6, 2020.You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the provider is not eligible for Medicare billing of services.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan cannot pay a provider who has opted out of, or been excluded or precluded from the Medicare Program.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The file shows that the Plan made multiple requests for documentation showing the provider was 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 medical services provided on January 6, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the colonoscopy with polyp removal provided on October 4, 2019.You asked the Plan to waive the copay for the services provided. The Plan denied your request. The Plan says the cost share was applied correctly per your benefit.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 $325 copay for outpatient surgery. You have been asked to pay a $325 copay for the services provided. The services fall within the outpatient surgery 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 copay for the colonoscopy with polyp removal provided on October 4, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a custom wheelchair (E1399). You asked the Plan to pre-approve a custom wheelchair. You say that you are appealing the denial of a custom wheelchair.The Plan denied your request. The Plan says Medicare does not cover durable medical equipment for enrollee's residing in facilities not designated as their home by Medicare rules.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home. Records show that a custom wheelchair is being requested for use in a SNF or hospital.Therefore, we decided that the Plan does not have to pre-approve a custom wheelchair (E1399).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve post removal (CPT D2955) and endodontic therapy on a premolar tooth (CPT D3320).You asked the Plan to pre-approve the post removal and the endodontic therapy. You say that  The Plan denied your request. The Plan says the services which remain in dispute are not covered 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 pre-approve post removal (CPT D2955) and endodontic therapy on a premolar tooth (CPT D3320).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services you received from December 31, 2019 and January 14, 2020.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says it is not appropriate to report unspecified, left or right diagnosis codes when a more specific code is available.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. We looked at the file and the rules. The provided services were billed with diagnoses of varicose veins of right lower extremity, and left lower extremity. If a bilateral diagnosis code exists for the services provided, a single code should be used. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the medical services you received from December 31, 2019 and January 14, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services. You asked the Plan to pay for the ambulance services. You say that you would like to appeal the Plan's refusal to pay for the service. You say that you are ninety one years old and when you fall you cannot get up on your own. You stated that on the date of service you were with your niece who was unable to help you up. You had fallen and bruised your knee however you say that you did not need to go to the hospital. You say that you know how to take case of a bruise and asked the Plan to reconsider paying the claim. 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 December 24, 2019. 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a shoulder-hand-wrist orthosis (L3960) provided to the enrollee on August 6, 2019. You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The rules say for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. When conducting a review of a covered DME item, ordered by a physician, the contractor shall ensure that the physician saw the beneficiary and conducted a face-to-face assessment. Therefore, we decided that the Plan does not have to pay for a shoulder-hand-wrist orthosis (L3960) provided to the enrollee on August 6, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lidocaine patch.
You asked the Plan to pre-approve self-administered drug. You say that you are appealing. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.
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 pre-approve Lidocaine patch.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied
your request. The Plan says there is a lack of medical necessity.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above are met. Custodial care is 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 admission. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing
service needs. There are no identifiable skilled therapy service needs. You do not require skilled nursing or
therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an
inpatient basis in a skilled nursing facility setting.
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 admission have not been met. Therefore, we decided that the Plan does not
have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthosis (L1833x2) and suspension sleeves (L2397x2) provided December 18, 2019.
You asked the Plan to pay for the orthoses. You say that you are appealing on behalf of the enrollee to document the medical necessity of a knee brace for treatment of osteoarthritis. The Plan denied your request. The Plan says the records do not support the billed service.
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 orthoses. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found while the appeal letter purports that the enrollee has osteoarthritis of the knees, the provided medical records do not support this. The documentation does not include a complaint of knee pain, detailed history of any knee problem(s), evidence of recent knee injury or surgery, associated symptoms or physical examination of the knees, including weakness and/or deformity. There is no evidence of diagnostic evaluation (i.e. x-rays) or prescription therapy provision/response (i.e. prescription meds, injections, PT/OT). Therefore, the documentation does not support the medical necessity or reasonableness of the provided 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 orthoses have not been met. Therefore, we decided that the Plan does not have to pay for knee orthosis (L1833x2) and suspension sleeves (L2397x2) provided December 18, 2019.
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 20, 2020.
You asked the Plan to pay for the complete series of intraoral x-rays. You say that you were not aware that this x-ray was not covered and thought your dentist would have known it was not covered. You also say that you were not given a choice on what x-ray to have done. The Plan denied your request. The Plan says this service 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, the requested items or services are not among those covered under this benefit. The contract clearly states that bitewing x-rays are the only covered x-rays. Therefore, we decided that the Plan does not have to pay for the complete series of intraoral x-rays provided on February 20, 2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve intraarticular injection of hyaluronan (Monovisc). You asked the Plan to pre-approve Monovisc injection. You say that this drug gives you the ability to continue driving, walk comfortably, and sleep without pain. The Plan denied your request. The Plan says that the denial of authorization for this service is correct, because this drug has not been proven to help your condition. 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 medical records regarding your request for coverage. We requested this information, but it was not provided to us. Without this information, the Plan has not shown that its decision to deny coverage for intraarticular injection of Monovisc is medically correct or justified according to Medicare rules. Therefore, we decided that the Plan has to pre-approve intraarticular injection of hyaluronan (Monovisc).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on January 30, 2020.
You asked the Plan to pay for the dental service. You say that you were told by 2 people that the x-ray and exam would be covered. The Plan denied your request. The Plan says the limited oral evaluation is not a preventive dental service. The Plan also says that the limited oral evaluation is not 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 limited oral evaluation is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on January 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse the full amount for the dental services provided from August 5, 2019 to September 20, 2019 by out of network providers. You asked the Plan to reimburse the full amount for the dental services. You say that you received the dental services from an in network provider that you found on a list provided by the Plan. You also say that the services you received were medically necessary. The Plan denied your request. The Plan says there is an annual maximum benefit of $1,000. The Plan says this benefit has been exhausted. The Plan also says that both of the providers in this case are out of network providers. 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 annual maximum benefit has been exhausted. Additionally, the record shows that only one provider is in network at this office and you did not see him. Therefore, we decided that the Plan does not have to reimburse the full amount for the dental services provided August 5, 2019 to September 20, 2019 by out of network providers.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a shoulder-hand-wrist orthosis (L3960) provided to the enrollee on January 15, 2020. You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition. The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use. The record shows that documentation submitted did not indicate the provider discussed the need for the billed supply code, so the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to pay for a shoulder-hand-wrist orthosis (L3960) provided to the enrollee on January 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids (V5261) purchased January 23, 2020 from an out-of-network-provider. You asked the Plan to pay for the hearing aids. You say that you feel that the plan representative should have explained in more detail instead of misleading you by sending you the form and telling you it was okay to buy the hearing aids from this provider. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. Non-emergent services with non-contracted providers require prior-authorization prior to services being rendered. Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when purchased from an in-network provider. We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids (V5261) purchased January 23, 2020 from an out-of-network-provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and related services provided on October 15, 2019 by an out of network (OON) provider. You asked the Plan to pay for these OON services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit. 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 has network providers available who can provide 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 office visit and related services provided on October 15, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the smoking and tobacco use cessation counseling provided on November 11, 2019. You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered benefit for the diagnoses listed. The Plan must follow Medicare rules. Medicare rules say that claims for counseling to prevent tobacco use services shall be submitted with an applicable diagnosis code. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the smoking and tobacco-use cessation counseling visit (99406) have not been met. Specifically, a supported diagnosis code was not billed on the claim as required by Medicare rules. Therefore, we decided that the Plan does not have to pay for the smoking and tobacco use cessation counseling provided on November 11, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for monitoring services (95951) provided on July 24, 2019.
You asked the Plan to pay for the monitoring services. 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 95951 is monitoring for localization of cerebral seizure focus by cable or radio, 16 or more channel telemetry, combined electroencephalographic (EEG) and video recording and interpretation (e.g., for presurgical localization), each 24 hours. 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 monitoring services. Our reviewer says that CPT code 95951 does not meet criteria for billing or reimbursement consideration. Our reviewer found the documentation does not support the service billed. The record supports a portable computerized EEG. 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 monitoring services have not been met. Therefore, we decided that the Plan does not have to pay for monitoring services (95951) provided on July 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a fully-electric hospital bed.
You asked the Plan to pre-approve the bed. You say that you do not have the strength to operate the semielectric
hospital bed. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a fully-electric
hospital bed