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

We decided that the Plan does not have to waive the copayment for ambulance services (A0426) and ground mileage (A0425), provided on December 3, 2020.

You asked the Plan to waive the copayment for ambulance and mileage. 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 $200 copayment for ambulance services. 

You have been asked to pay a $200 copayment for ambulance and mileage. These services fall within the ambulance 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 ambulance services (A0426) and ground mileage (A0425), provided on December 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and the complete series x-ray (D0210) provided on February 24, 2020.

You asked the Plan to pay for the dental services. You say that you have been experiencing TMJ pain. You say that the pain is affecting your whole head. The Plan denied your request. The Plan says 1 comprehensive oral evaluation is covered every 3 plan years. The Plan says that 1 complete series x-ray is covered every 3 plan years. The Plan also says that the frequency limits for these services have been exceeded.

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 and the services are listed as covered, the frequency limits have been exceeded. The record shows that the Plan paid for a comprehensive oral evaluation that you received on November 7, 2019. The record shows that the Plan paid for a complete series x-ray that you received on June 13, 2019. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and the complete series x-ray (D0210) provided on February 24, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on December 17, 2020.

You asked the Plan to pay for the ambulance services. You say that you were following the Covid executive order for treatment in place. 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 17, 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 December 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuromuscular stimulator (E0745) provided on
September 20, 2020.

You asked the Plan to pay for the neuromuscular stimulator. 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
include an itemized billing/shipping invoice to verify the billed supply.

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 for the supplies provided in this case. Specifically, the
documentation submitted does not include an itemized billing/shipping invoice to verify the billed supply. 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 the neuromuscular stimulator (E0745) provided on September 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the consultation-diagnostic service provided by a dentist or physician other than the requesting dentist or physician (D9310) and the panoramic radiographic image (D0330) provided on February 24, 2021.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the consultation-diagnostic service provided is not a covered benefit under your dental policy. Additionally, you have exceeded the allowable frequency for the panoramic radiographic image provided.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of these services have not been met. Specifically, the consultation-diagnostic service provided is not a covered benefit under your dental policy. Additionally, the Plan contract covers a panoramic radiographic image once every five years. You previously received this service on February 16, 2021. The Plan issued payment to the provider for this service on February 21, 2021. You have exhausted the allowable benefit for this service. Therefore, we decided that the Plan does not have to pay for the consultation-diagnostic service provided by a dentist or physician other than the requesting dentist or physician (D9310) and the panoramic radiographic image (D0330) provided on February 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a removable foot insert (L3000) provided on January 18, 2021.

You asked the Plan to pay for a foot insert. You say that the requested item is a necessity for the enrollee's care. The Plan denied your request. The Plan says this item is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. 

Records do not show that the enrollee wears a leg brace. The enrollee does suffer from diabetic foot disease; however, the requested orthotics coded L3000 are not diabetic orthotics. Although the requested orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of the requested orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pay for a removable foot insert (L3000) provided on January 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient office visit (99213) chiropractic manipulation
(98943) Mechanical traction (97012) manual therapy techniques (97140) provided February 3, 2020 to
February 10, 2020.

You asked the Plan to pay for the chiropractic services. You say that please accept the following medical
records for reconsideration on the following dates of services. The Plan denied your request. The Plan says
these services are not covered when performed by a chiropractor.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation.

The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that
the Plan does not have to pay for outpatient office visit (99213) chiropractic manipulation (98943) Mechanical
traction (97012) manual therapy techniques (97140) provided February 3, 2020 to February 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an orthosis (L0642).

You asked the Plan to pay for the orthosis. You say that the orthosis was medically necessary. The Plan denied your request. The Plan says the documentation does not support the services billed.

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. No itemized shipping documentation was provided. 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 an orthosis (L0642).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for therapeutic procedure, 1 or more areas, each 15 minutes (97110) provided October 2, 2020 to October 9, 2020.

You asked the Plan to waive the copayment for the outpatient therapy services. You say that you were informed by your doctor that this was covered fully by your insurance. You would not have gone to physical therapy had you known there was going to be an expense for you to pay. The Plan denied your request. The Plan says the claim was processed with the correct copayment applied per the Evidence of Coverage.

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 $40 copayment for each covered physical therapy and speech language therapy visit.

You have been asked to pay $160 ($40 x 4 visits) for the outpatient therapy services. The outpatient therapy services fall within the Outpatient Rehabilitation 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 therapeutic procedure, 1 or more areas, each 15 minutes (97110) provided October 2, 2020 to October 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit rendered on March 9, 2021.

You asked the Plan to pay for these services. You say that the exam was for the Special Olympics. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. The rules say that examinations performed for a purpose other than treatment or diagnosis of a specific illness, symptoms, complaint, or injury are excluded from coverage. 

We looked at the file and Medicare rules. The file shows that the examination at issue was performed for a purpose other than treatment or diagnosis of an illness or injury. 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 office visit rendered on March 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a core buildup, including any pins when required (D2950), endodontic therapy (D3330), and crown - porcelain/ceramic (D2740), provided on January 25, 2021.

You asked the Plan to pay for a core buildup, endodontic therapy and a crown. You say that you were not aware the provider was out-of-network. The Plan denied your request. The Plan says the services were obtained out-of-network.

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. Specifically, you obtained services from an out-of-network provider, and therefore, the services are not a covered benefit. Therefore, we decided that the Plan does not have to pay for a core buildup, including any pins when required (D2950), endodontic therapy (D3330), and crown - porcelain/ceramic (D2740), provided on January 25, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services provided on December 31, 2020.

You asked the Plan to waive the copayment for inpatient hospital 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 $200 copayment per day one through five for inpatient hospital care. 

You have been asked to pay a $200 copayment per day one through five for inpatient hospital services. These services fall within the inpatient hospital care 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 inpatient hospital services provided on December 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia (01200) provided on October 13, 2020.

You asked the Plan to pay for anesthesia. You say that this should be covered. The Plan denied your request. The Plan says this was not billed with the correct diagnosis.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Some ICD-10-CM codes indicate laterality, specifying whether the condition occurs on the left, right or is bilateral. If the side is not identified in the medical record, assign the code for the unspecified side.

We find that the billed diagnosis, M16.9, osteoarthritis of hip, unspecified, is not supported in the records. Specifically, the records show a diagnosis of osteoarthritis in the right hip. Based on this information, we decided that Medicare rules for coverage of anesthesia have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia (01200) provided on October 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a manual wheelchair (K0001) provided on January 29, 2021.

You asked the Plan to pay for a manual wheelchair. You say that this was medically necessary. The Plan denied your request. The Plan says the requirements for coverage have not been met.

The Plan must follow Medicare rules. Medicare rules say that if a Written Order Prior to Delivery (WOPD) is not obtained prior to delivery, payment will not be made for that item even if a WOPD is subsequently obtained. 

We looked at the file and Medicare rules. The records show that an order for a manual wheelchair was obtained from you physician after the item at issue was purchased. Based on this information, we decided that Medicare rules for coverage of a manual wheelchair have not been met. Therefore, we decided that the Plan does not have to pay for a manual wheelchair (K0001) provided on January 29, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for SNF services provided from August 24, 2020, through September 22, 2020.

You asked the Plan to pay for the SNF services. The Plan denied your request. The Plan says the member was not making meaningful progress and did not have skilled nursing needs.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 pay for the SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that based on the documentation provided, the enrollee did not qualify for SNF coverage from August 24, 2020, through September 22, 2020. The enrollee did not have documented skilled nursing needs. The enrollee did not have documented skilled therapy needs. Daily skilled services were not shown to be required to establish a maintenance program or to prevent deterioration of the enrollee's 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 the SNF services have not been met. Therefore, we decided that the Plan does not have to pay for SNF services provided from August 24, 2020, through September 22, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the excision services coded 11644 provided on December 1, 2020.

You asked the Plan to pay for the excision services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.

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 11644 is excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 3.1 to 4.0 cm.

We find that CPT code 11644 is not supported in the medical record. Specifically, the operative report did not include documentation of an excision, malignant lesion including margins of the face, ears, eyelids, nose, lips; excised diameter 3.1 to 4.0 cm; therefore, this code cannot be verified. Based on this information, we decided that Medicare rules for coverage of the excision services have not been met. Therefore, we decided that the Plan does not have to pay for the excision services coded 11644 provided on December 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 3D photographic image (D0351) provided on February 25, 2021.

You asked the Plan to pay for the 3D photographic image. You say that you would like these services to be covered. 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. Therefore, we decided that the Plan does not have to pay for the 3D photographic image (D0351) provided on February 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the durable medical equipment provided on January 14, 2021.

You asked the Plan to pay for the durable medical equipment. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.

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 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 the durable medical equipment provided on January 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99202) provided January 11, 2021.

You asked the Plan to pay for the chiropractic services. You say that every time you go to a new provider the patient has to fill out a background profile. You do not understand why Medicare pays for this but not at a chiropractic office. The Plan denied your request. The Plan says this service is not covered when rendered by a Chiropractor.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 

The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the outpatient office visit (99202) provided January 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics provided on September 11, 2020.

You asked the Plan to pay for foot orthotics. You say that this is medically necessary. The Plan denied your request. The Plan says this item is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. 

Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pay for foot orthotics provided on September 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator.

You asked the Plan to pre-approve the ventilator. You say that this is medically necessary. The Plan denied your request. The Plan says an E0471 device could be approved instead.

The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 

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 ventilator. Our reviewer says that the requested ventilator is not medically reasonable and necessary. Our physician reviewer found you have COPD, but the records do not include documentation of C02 retention while in a stable state. There is no documented failure of BiPAP. Medicare does not cover a ventilator when used as BiPAP. The requested ventilator settings can be provided via BiPAP. 

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 ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator.