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

We decided that the Plan does not have to pay for the electronic analysis of implanted neurostimulator pulse generator or transmitter (95972) provided on August 18, 2020.
You asked the Plan to pay for the electronic analysis. You say that you would like reconsideration because this service was billed correctly. The Plan denied your request. The Plan says CPT code 95972 has a global period of "XXX" which indicates that the global concept does not apply and modifier 58 is not applicable.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find that CPT code 95972 58 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code 95972 has a global period of XXX. This means that the global concept does not apply and modifier 58 is not applicable. Based on this information, we decided that Medicare rules for coverage of the electronic analysis have not been met. Therefore, we decided that the Plan does not have to pay for the electronic analysis of implanted neurostimulator pulse generator or transmitter (95972) provided on August 18, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the diagnostic digital breast tomosynthesis services coded 77062 provided on August 6, 2020.
You asked the Plan to pay for the diagnostic digital breast tomosynthesis 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 payable.
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 77062 is diagnostic digital breast tomosynthesis; bilateral. We find that CPT code 77062 is not supported in the medical record. Specifically, this code has a status code of "I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for coverage of the diagnostic digital breast tomosynthesis services have not been met. Therefore, we decided that the Plan does not have to pay for the diagnostic digital breast tomosynthesis services coded 77062 provided on August 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a root canal (D3310), prefabricated post and core in addition to a crown (D2954), prophylaxis (D1110), the unspecified preventive service (D1999 x 2), bitewing x-rays (D0274), the periapical x-ray (D0220), the oral evaluation (D0120), and the crown (D2740) provided from May 30, 2020 to June 8, 2020. You asked the Plan to pay for the dental services. You say that the provider submitted the claims not knowing that you had to submit them for reimbursement. The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan says that payment cannot be made for services that you receive from a provider who has opted out of Medicare. The Plan also says that if you use a provider that has opted out of Medicare you will not receive reimbursement. The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for a root canal (D3310), prefabricated post and core in addition to a crown (D2954), prophylaxis (D1110), the unspecified preventive service (D1999 x 2), bitewing x-rays (D0274), the periapical x-ray (D0220), the oral evaluation (D0120), and the crown (D2740) provided from May 30, 2020 to June 8, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transthoracic echocardiography for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says the clinical information provided does not meet the criteria.
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 services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the enrollee has no documented heart disease, no documented cardiac physical exam abnormalities, no
documented electrocardiographic abnormalities and scheduled for a non high-risk surgical procedure. In this
circumstance the records do not support the medical necessity for an echocardiogram. Coverage criteria are not
met since there is no documented covered indication for the procedure.
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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve transthoracic echocardiography for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe lab services you had on August 14, 2020.You asked the Plan to waive the copayment forthe lab services. You say that you had these labs at your doctor's office, so there should be no copayment.The Plan denied your request. The Plan says you were charged this copayment 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 $20 copayment for lab services at a freestanding laboratory. You have been asked to pay a $20 copayment for the lab services. The records show that these labs were drawn not in your doctor's office, but at a freestanding lab facility.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 forthe lab services you had on August 14,2020
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomographic colonography (CTC) services.
You asked the Plan to pre-approve the CTC services. You say that the clinical information provided supports the need for the requested service. The Plan denied your request. The Plan says the clinical information provided describes the requested CTC as being for screening purposes. The Plan says that the requested test is not indicated at this time.
The Plan must follow Medicare rules. Medicare rules say that screening computed tomographic colonography are non-covered.
Therefore, we decided that the Plan does not have to pre-approve computed tomographic colonography (CTC) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the portable wheelchair ramp.

You asked the Plan to pre-approve the wheelchair ramp. You say that it is medically necessary for the enrollee to have a lightweight portable foldable aluminum wheelchair ramp with which to have his caregivers safely load and unload the wheelchair.The Plan denied your request. The Plan says this item is not covered.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plan does not have to pre-approve the portable wheelchair ramp
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe bone replacement graft for ridge preservation provided on July 2, 2020.You asked the Plan to pay forthe bone replacement graft. You say that you were advised that you would only have to pay $400 for a bridge support, and the rest would be covered. You also say that now you are having to pay $800, and should only have a zero copay.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 forthe bone replacement graft for ridge preservation provided on July 2, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadditional routine transportation trips.You asked the Plan to pre-approveadditional routine transportation trips. You say that you have no other method of transportation.The Plan denied your request. The Plan says that your benefit is exhausted.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. The Plan covers a maximum of sixteen (16) trips per year. 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.Therefore, we decided that the Plan does not have to pre-approveadditional routine transportation trips
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approvea single photon emission computed tomography (SPECT) DaTscan of the brain (78803).You asked the Plan to pre-approvethis service. You say that this service is medically necessary to help guide managementas an abnormal result would prompt treatment with medications for Parkinson'sDisease.The Plan denied your request. The Plan says that the requested service is not medically necessary.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. 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 this service. Our reviewer says that the requested service is considered medically reasonable and necessary in this case. Our physician reviewer found that given the disease specific therapy required to treat Parkinsonism and the side effects of the therapy, it is important to be secure of the diagnosis of Parkinsonism to direct therapy.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have been met.Therefore, we decided that the Plan has to pre-approvea single photon emission computed tomography (SPECT) DaTscan of the brain (78803).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on June 25, 2020 by an out of network (OON) provider.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services were rendered by an out-of-network provider without prior authorization.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 medical services provided on June 25, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the full amount forthe complete upper denture (D5110) and the complete lower denture (D5120) provided on May 7, 2019.You asked the Plan to pay the full amount forthe dental items. You say that the dentures do not fit properly. You say that you cannot eat with the dentures and they are painful. You say that the provider did nothing to help. You say that you asked for your money back. You say that you were advised there are not providers in the office now. You also say that you do not want to go back to that office again.The Plan denied your request. The Plan says there is a maximum allowance of $650 for preventive and comprehensive dental services, including dentures. The Plan also says that the benefit has been exhausted.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 of $650 has been exhausted. The record shows that the Plan paid $650 towards the services that you received on the date of service in this case. Therefore, we decided that the Plan does not have to pay the full amount forthe complete upper denture (D5110) and the complete lower denture (D5120) provided on May 7, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies rendered.


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 proof of delivery.

The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS suppliers are required to maintain proof of delivery.

We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. The proof of delivery does not contain an order number or details to corroborate the submitted delivery ticket. 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 continuous glucose monitor (CGM) supplies rendered.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay formoderate sedation provided on July 22, 2019.You asked the Plan to pay formoderate sedation (99152). You say that the Plan should pay this claim.The Plan denied your request. The Plan says the documentation submitted did not indicate that moderate sedation was performed.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 99152 is Moderate sedation services provided by thesame physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older. We find that CPT code 99152 is not supported in the medical record. Specifically, the medical notes state that no sedation was given. Based on this information, we decided that Medicare rules for coverage of moderate sedation (99152) have not been met.Therefore, we decided that the Plan does not have to pay formoderate sedation provided on July 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe pain management services rendered on July 30, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied.In this case, the MUE for CPT codes 64494 and 64495 is 1. You billed 2 units of each of these codes, exceeding the MUE. 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 forthe pain management services rendered on July 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series of intraoral x-rays, preventive procedure,
and occlusal adjustment provided on July 16, 2020.
You asked the Plan to pay for the complete series of intraoral x-rays, preventive procedure, and occlusal
adjustment. You say that you feel that the Plan covers some x-rays. The Plan denied your request. The Plan
says these services are not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
complete series of intraoral x-rays, preventive procedure, and occlusal adjustment provided on July 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a nebulizer with regulator provided on June 1, 2020.
You asked the Plan to pay for the nebulizer with regulator. You say that went to an in-network pharmacy to
purchase the nebulizer and the pharmacist told you that they would need to order it, which would take a few
days. You say that you could not go days without the nebulizer, so the pharmacist referred her to the out-of-network
pharmacy where you were able to obtain the nebulizer. The Plan denied your request. The Plan says
must receive care from a network 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 did not pre-approve the
nebulizer with regulator. We found no exception that would require the Plan to pay for these items. Therefore,
we decided that the Plan does not have to pay for a nebulizer with regulator provided on June 1, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient and inpatient rehabilitation services provided from February 26, 2020, to March 12, 2020.
You asked the Plan to waive the copayment for the inpatient and inpatient rehabilitation services. You say that were in a skilled nursing facility and should have no copayment. The Plan denied your request. The Plan says you were charged this copayment 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 $225 copayment for days 1-7 for Inpatient Hospital Care. You have been asked to pay a $225 copayment for days 1-7 for the inpatient and inpatient rehabilitation services. The inpatient and inpatient rehabilitation 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 the inpatient and inpatient rehabilitation services provided from February 26, 2020, to March 12, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the co payment for inpatient care provided.

You asked the Plan to waive 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 $275 copayment per day for days 1 to 5 for inpatient hospital care. 

You have been asked to pay a $275 copayment per day for days 1 to 5 for inpatient care. This service falls 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 care provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for electrocardiogram, routine ECG with at least 12-leads; interpretation and report only (93010) provided June 2, 2020.
You asked the Plan to pay for the electrocardiogram. You say that you have attached the necessary medical documentation supporting the service and procedure performed. Please review and adjust the denied claim accordingly. The Plan denied your request. The Plan says payment for this service would be included in the facility PPS payment.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. Payment for the service would have been included under the facility claim. Payment for this service is the responsibility of the facility or hospital. Based on this information, we decided that Medicare rules for coverage of the electrocardiogram have not been met.
Therefore, we decided that the Plan does not have to pay for electrocardiogram, routine ECG with at least 12-leads; interpretation and report only (93010) provided June 2, 2020.