Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on April 13, 2021.
You asked the Plan to pay for a limited oral evaluation. You say that your general dentist could not solve your issue and sent you to another provider. The Plan denied your request. The Plan says the service is a covered benefit, but you have exceeded the frequency limit of one every Plan year.
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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a limited oral evaluation have not been met. Specifically, the record shows that you had exceeded the frequency limit prior to this service on March 17, 2021. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on April 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for neuromuscular stimulator, electronic shock unit (E0745) provided September 3, 2020.
You asked the Plan to pay for electronic shock unit. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says there is no evidence of an established relationship between the enrollee and the ordering physician and the records did not sufficiently document the enrollee's medical condition to support the medical necessity for the billed supply code
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid proof of delivery, or a delivery ticket to indicate the specific supplies. 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 neuromuscular stimulator, electronic shock unit (E0745) provided September 3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lynch Syndrome testing.
You asked the Plan to pre-approve genetic testing. You say that due to the enrollee's children having this gene, you find it necessary to see if this gene was passed down from the maternal or paternal side. The Plan denied your request. The Plan says the denial of authorization for this testing is correct, because this test is not a Medicare covered benefit.
The Plan must follow Medicare rules. Medicare rules say that Lynch Syndrome testing for status of carrier or family studies is not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pre-approve Lynch Syndrome testing.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular gene panel provided on November 17,
2020.
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says Medicare
denies coverage for all cardiovascular risk assessment panels, except the basic lipid panel.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed in the Medicare rules section, are not covered.
We looked at the file and the rules. The test at issue in this appeal was requested for screening purposes.
Medicare does not cover this testing for screening purposes. Therefore, we decided that the Plan does not have
to pay for the cardiovascular gene panel provided on November 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve TMS (CPT code(s): 90867, 90868, 90869), for the enrollee.
You asked the Plan to pre-approve the TMS. You say that this is a Food and Drug Administration (FDA) approved treatment that offers safe and effective options to help patients break the cycle of nicotine dependence with exposure to the possible harmful side effects of nicotine replacement therapies. The Plan denied your request. The Plan says this procedure is only approved for the treatment of major depressive disorder and has not been approved for smooth cessation.
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 TMS. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the labeled FDA indication for use for the TMS therapy states that, "TMS therapy is indicated for the treatment of Major Depressive Disorder in adult patients who have failed to receive satisfactory improvement from prior antidepressant medication in the current episode." The review indicates that the items/services at issue in this case are not medically reasonable or 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 TMS have not been met. Therefore, we decided that the Plan does not have to pre-approve TMS (CPT code(s): 90867, 90868, 90869), for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an EGD provided on March 2, 2021.
You asked the Plan to waive the copayment for an EGD. You say that you were told you would not owe a copayment as the procedure was preventative. 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 $350 copayment for outpatient surgery, including services provided at hospital outpatient facilities. You received an EGD at an outpatient hospital facility on March 2, 2021. An EGD is considered a diagnostic surgical procedure and is not considered preventative. Therefore, you are responsible to pay the $350 copayment. You have been asked to pay a $350 copayment for an EGD. An EGD falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 an EGD provided on March 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 2D oral/facial photographic image, oral hygiene instructions and gingival irrigation provided on March 15, 2021.
You asked the Plan to pay for the 2D oral/facial photographic image, oral hygiene instructions and gingival irrigation. You say that too many x-rays were taken, and you don't have the money to pay. You say that you were informed you don't owe anything. The Plan denied your request. The Plan says the services 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 pay for the 2D oral/facial photographic image, oral hygiene instructions and gingival irrigation provided on March 15, 2021.
Your complaint about being treated badly is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection services rendered on November 24, 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 procedure code 62324 is not supported.
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 62324 is injection(s), including indwelling catheter
placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic,
antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or
subarachnoid, cervical or thoracic; without imaging guidance.
We find that CPT code 62324 is not supported in the medical record. Specifically, there is no documentation of an injection for continuous infusion or intermittent bolus was performed. 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 injection services rendered on November 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a manual wheelchair.
You asked the Plan to pre-approve a manual wheelchair. You say that this request is medically necessary for you to participate in activities outside of the home. The Plan denied your request. The Plan says coverage is not provided for durable medical equipment to be used outside of the home.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a manual wheelchair.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0483) provided on August 12, 2020.
You asked the Plan to pay for drug testing. You say that this is supported in the records. The Plan denied your request. The Plan says this was billed with an incorrect POS.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing (G0483) provided on August 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a power recliner chair purchased on January 15, 2021, from a retail furniture store.

You asked the Plan to pay for a power recliner chair. You say that you were told the item at issue would be covered under your plan. The Plan denied your request. The Plan says rules for payment have not been met because the provider in this case is not enrolled in the Medicare program.

The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for a power recliner chair purchased on January 15, 2021, from a retail furniture store.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.
You asked the Plan to pre-approve additional routine transportation trips. You say that you have dialysis three (3) times per week with no other ride to get to treatment. The Plan denied your request. The Plan says this request exceeds your benefit.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. This request exceeds your benefit. Your 2021 EOC states that enrollees must pay a $0 copayment for up to ten (10) one-way trips to plan-approved locations every year. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a cone beam computed tomography capture and interpretation (D0367) provided on April 13, 2021.
You asked the Plan to pay for a cone beam computed tomography capture and interpretation. You say that the service was necessary. The Plan denied your request. The Plan says the service at issue is not a covered 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 pay for a cone beam computed tomography capture and interpretation (D0367) provided on April 13, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from January 6, 2021 to January 28, 2021.
You asked the Plan to pay for home health services. You say that you have always billed claims the same way. The Plan denied your request. The Plan says this was not billed on the correct type of bill.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, this claim was billed with type of bill code 323, which is not an appropriate type of bill code for these services. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from January 6, 2021 to January 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for bilateral knee orthoses (CPT code L1833) and suspension sleeves (CPT code L2397) provided to the enrollee from April 6, 2021, through April 7, 2021, by an out-of-network provider.
You asked the Plan to pay for the orthoses and sleeves. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says the documentation indicates services are not necessary for treatment of the enrollee's condition.
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 and sleeves. Our physician reviewer found the documentation in the case file does not support that the requested knee orthoses with sleeves were medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. There is no documentation of recent injury to, or recent surgical procedure on, either of the enrollee's knees, and there is insufficient credible objective documentation of joint laxity. 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 and sleeves have not been met. Therefore, we decided that the Plan does not have to pay for bilateral knee orthoses (CPT code L1833) and suspension sleeves (CPT code L2397) provided to the enrollee from April 6, 2021, through April 7, 2021, by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for spherocylinder lenses (V2303), lens tint (V2744) and lenses (V2782) provided on February 19, 2021.
You asked the Plan to pay for spherocylinder lenses, lens tint and lenses. You say that you are not happy with the coverage maximum and you would like to appeal the amount owed. The Plan denied your request. The Plan says you exhausted your benefit and are responsible for the remaining balance.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan contract says that you have a $200 allowance every calendar year to use for eyeglasses, frames, lenses or contact lenses. We looked at the file and the Plan's rules. The records show you exhausted your $200 maximum benefit on February 19, 2021. The records also show that you purchased frames at an allowed amount of $110 and partial payment for your spherocylinder lenses at an allowed amount of $90. You received the total allowance benefit of $200. Based on this information, we decided that the Plan's rules for coverage of spherocylinder lenses, lens tint and lenses have not been met. Therefore, we decided that the Plan does not have to pay for spherocylinder lenses (V2303), lens tint (V2744) and lenses (V2782) provided on February 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the unspecified maxillofacial prosthesis, by report (D5999) provided January 5, 2021.
You asked the Plan to pay for the unspecified maxillofacial prosthesis. You say that you required services from a prosthodontist and there are not prosthodontists in the Plan's network. The Plan denied your request. The Plan says the service was provided OON without pre-approval and therefore the 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. The Plan covers the unspecified maxillofacial prosthesis when provided by a participating provider. We looked at the file and Medicare rules. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Based on this information, we decided that the Plan's rules for coverage of the unspecified maxillofacial prosthesis have not been met. Therefore, we decided that the Plan does not have to pay for the unspecified maxillofacial prosthesis, by report (D5999) provided January 5, 2021.
Your complaint about the Plan potentially not having a prosthodontist in the network and issues finding a provider to render the services is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Guardant360 panel testing provided on March 23, 2021.
You asked the Plan to pay for genetic testing. You say that the enrollee's treating physician ordered this testing to determine if there was a more effective therapy to treat the enrollee's condition. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this testing was not billed with the appropriate coding.
The Plan must follow Medicare rules. Medicare rules say that genetic panel testing must be billed with a single procedure code. We looked at the file and Medicare rules. This testing was not billed with the appropriate coding. Based on this information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for Guardant360 panel testing provided on March 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglass frames (V2020) and bifocal lenses (V2200) provided on September 23, 2020.
You asked the Plan to pay for frames and bifocal lenses. You say that a provider visited your home due to Coronavirus and mobility issues. You also say you would like to be reimbursed as this is a benefit you are entitled to. The Plan denied your request. The Plan says services were provided by an out-of-network provider without prior authorization.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when you obtain authorization from the Plan prior to seeking care. We looked at the file and the Plan's rules. The provider in this case is not part of the Plan's vision network. Prior authorization was not obtained. Based on this information, we decided that the Plan's rules for coverage of frames and bifocal lenses have not been met. Therefore, we decided that the Plan does not have to pay for eyeglass frames (V2020) and bifocal lenses (V2200) provided on September 23, 2020.