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

We decided that the Plan does not have to pay for a foot x-ray (73620) provided on November 13, 2019.
You asked the Plan to pay for the foot x-ray. 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. We asked our coder 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 foot x-ray. Our reviewer says that CPT code 73620 does not meet criteria for billing or reimbursement consideration. Our reviewer found the documentation does not include any evidence that the x-ray was performed. 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 foot x-ray have not been met. Therefore, we decided that the Plan does not have to pay for a foot x-ray (73620) provided on November 13, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued physical therapy (PT) for the enrollee.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 these services. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the enrollee has back and knee pain and debilitation. He has had numerous completed PT sessions and has lower limb major muscle strength of four out of five as of February 25, 2020. While PT is generally accepted as specific and effective for the enrollee's condition, he does not require the unique skills of a professional therapist are required to safely and effectively provide treatment. There is no indication that prior PT provided sustained and significant improvement. His residual deficits can be sufficiently met with a home exercise program.
We looked at this physician's review, the file, and Medicare rules. 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 pre-approve continued physical therapy (PT) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Metolazone.
You asked the Plan to pre-approve Metolazone. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not a covered benefit.
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 Metolazone.
Benefits for Metolazone may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal scaling and root planing (D4341 x 4) provided from November 26, 2019 to December 9, 2019.
You asked the Plan to pay for the dental services. You say that you went to have cleanings. The Plan denied your request. The Plan says periodontal scaling and root planing 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, periodontal scaling and root planing is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the periodontal scaling and root planing (D4341 x 4) provided from November 26, 2019 to December 9, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650) provided to the enrollee on December 10, 2019.You asked the Plan to pay forthe 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 orderedand 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 topay fora lumbar-sacral orthosis (L0650) provided to the enrollee on December 10, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6535.
You asked the Plan to pre-approve the compression stockings. You say that you require the stockings. The Plan denied your request. The Plan says compression stockings are a noncovered benefit.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6535 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6535.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a diagnostic mammography (77065) provided on October 1, 2019.
You asked the Plan to pay for the diagnostic mammography. You say that you would like reconsideration based on the record submitted. The Plan denied your request. The Plan says CPT code 77065 was previously processed and paid.
The Plan must follow Medicare rules. Medicare 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. Based on this information, we decided that Medicare rules for coverage of the diagnostic mammography have not been met. Specifically, the record indicates that CPT code has been previously processed and paid (77065). Therefore, we decided that the Plan does not have to pay for a diagnostic mammography (77065) provided on October 1, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe paramedicintercept services provided on November 17, 2019.You asked the Plan to pay forthe paramedic intercept services. You say that you did not request paramedic intercept services.The Plan denied your request. The Plan says that these services were not provided in a rural area.The rules say that Medicare pays for advanced life support (ALS) paramedic intercept services only when the services are furnished in a rural area. The paramedic intercept services at issue in this appeal were not furnished in a rural area.Therefore, we decided that the Plan does not have to pay forthe paramedic intercept services provided on November 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe office visit provided on January 8, 2020 by an out of network (OON) provider.You asked the Plan to pay forthese OON 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 when provided by an OON provider.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 forthe office visit provided on January 8, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more than $100 for eyeglasses provided on June 20, 2019.
You asked the Plan to pay more than $100 for the eyeglasses. The Plan denied your request. The Plan says the claim processed with the correct $100 benefit allowance for eyewear.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these servicers with a $100 allowance per calendar year. We looked at the file and the Plan's rules. The file shows that the Plan processed the claim with the correct $100 benefit allowance for eyewear. Therefore, we decided that the Plan does not have to pay more than $100 for the eyeglasses provided on June 20, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for Als specialized service disposable supplies provided on November 20, 2019.
You asked the Plan to pay for Als specialized service disposable supplies (A0394). You say that the ambulance services were medically necessary. The Plan denied your request. The Plan says these supplies are not separately payable by Medicare.
Medicare does not pay separately for ambulance supplies. The Plan follows the same rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Als specialized service disposable supplies (A0394) have not been met. Therefore, we decided that the Plan does not have to pay for Als specialized service disposable supplies provided on November 20, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on October 10, 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 knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on October 10, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the varicose vein treatment (6465, 36471, 76942 99212, 93971, 36470) to be provided out of network (OON).
You asked the Plan to pre-approve the varicose vein treatment. You say that the services are medically necessary. The Plan denied your request. The Plan says there are network providers who can render the services at issue.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the varicose vein treatment (6465, 36471, 76942 99212, 93971, 36470) to be provided out of network (OON).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an outpatient hospital clinic visit provided on November 12, 2019.
You asked the Plan to waive the deductible for clinic visit. You say that you do not believe this charge is correct and have been unsuccessful in finding out why it is described as clinic. The Plan denied your request. The Plan says the deductible amount you are being charged is correct.
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 $600 deductible for in-network hospital clinic visit. At the time this claim was processed, $0 of the $600 deductible had been met. The allowed amount of the claim is $85.75, resulting in a deductible obligation of $85.75. The item or service you asked the Plan to waive the deductible for falls within the benefit category Outpatient Hospital Services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $600 deductible for Outpatient Hospital Services. This cost sharing is a contractual obligation that had not been met at the time clinic visit was received on November 12, 2019. Therefore, we decided that the Plan does not have to waive the deductible for an outpatient hospital clinic visit provided on November 12, 2019.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve rhinoplasty (30400).
You asked the Plan to pre-approve rhinoplasty. You say that this is medically necessary. The Plan denied your
request. The Plan says that this is cosmetic.
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are
coverable. When nasal surgery, including rhinoplasty, is performed to improve nasal respiratory function,
correct anatomic abnormalities caused by birth defects or disease, or revise structural deformities produced by
trauma, the procedure may be considered reconstructive.
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 rhinoplasty. Our reviewer says that the
documentation supports that the planned procedure is reconstructive for the enrollee in this case. Our reviewer
found the purpose of the proposed procedure is to correct anatomic abnormalities caused by disease. The
physical exam of the nose documented hypertrophic scarring on the nasal tip and nasal dorsum, with saddle
nose deformity. Reconstructive surgery is performed on abnormal structures of the body caused by congenital
defects, developmental abnormalities, trauma, infection, tumors or disease. It is generally performed to
improve function, but may also be done to approximate a normal or symmetric appearance.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of rhinoplasty have been met. Therefore, we decided that the Plan has to preapprove
rhinoplasty (30400).
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for chiropractic manipulative treatment
(CMT) visits provided by from March 5, 2019 to September 10,
2019.
You asked the Plan to waive the copayments for chiropractic visits. You say that you believe your copayment
should only be $10 per visit. The Plan denied your request. The Plan says the copayment amounts you are
being charged are correct.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $20
copayment for each Medicare-covered chiropractic visit for manual manipulation of the spine to correct
subluxation. These visits were for manual manipulation of the spine to correct subluxation; therefore, the
Medicare-covered chiropractic copayment applies to each visit instead of the routine (not Medicare-covered)
chiropractic copayment. There were 7 visits, resulting in a total copayment obligation of $140
You have been asked to pay $20 copayment for each chiropractic visit. Chiropractic visits fall within the
Chiropractic 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 copayments for
chiropractic manipulative treatment (CMT) visits provided by from
March 5, 2019 to September 10, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee on December 11, 2019 by an out of network (OON) provider. You asked the Plan to pay for the office visit. You say that based on patient crisis we provided the service. The Plan denied your request. The Plan says that there was no referral for these services out of network
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 medical services provided to the enrollee on December 11, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for radiation therapy services provided from September 24, 2019 through October 11, 2019.
You asked the Plan to waive the coinsurance for radiation therapy services. You say that you were informed you would have no copayment. You say that you cannot afford this amount. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for each Medicare-covered radiation therapy service. You have been asked to pay $6,404.79, which is less than the standard 20% coinsurance for the radiation therapy services because you met your maximum out-of-pocket. The radiation therapy services fall within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for radiation therapy services provided from September 24, 2019 through October 11, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transthoracic echocardiogram (93307).
You asked the Plan to pre-approve the transthoracic echocardiogram. You say that the member has a history of
PHTN, has decreased heart function and shortness of breath The Plan denied your request. The Plan says it is
not medically necessary to augment clinical assessments with TTE measurements at more frequent than annual
examinations.
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 transthoracic echocardiogram. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found the member is clinically stable and the records do not support the medical
necessity for a repeat echocardiogram about 5 months after the prior exam.
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 transthoracic echocardiogram have not been met. Therefore, we decided that
the Plan does not have to pre-approve transthoracic echocardiogram (93307).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on November 12, 2019.
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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 drug testing rendered on November 12, 2019.