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

We decided that the Plan does not have to pay for lab testing (87633) provided November 18, 2020 to November 19, 2020.
You asked the Plan to pay for the lab testing. You say that this testing was medically necessary. The Plan denied your request. The Plan says this test is not a covered service.
The Plan must follow Medicare rules. Medicare rules say that Multiplex Nucleic Acid Amplified Tests for Respiratory Viruses that include more than 5 viral pathogens are non-covered. We looked at the file and Medicare rules. The panel included testing for more than 5 viral pathogens. Tests that include 6 or more viral pathogens are non-covered. Based on this information, we decided that Medicare rules for coverage of the lab testing have not been met. Therefore, we decided that the Plan does not have to pay for lab testing (87633) provided November 18, 2020 to November 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed (E0260).
You asked the Plan to pre-approve a semi-electric hospital bed. You say that the semi-electric hospital bed is medically necessary. The Plan denied your request. The Plan says you do not meet the established criteria for the semi-electric hospital bed.
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient: 1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 2. Requires attachments which can only be attached to a hospital bed; AND 3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 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 a semi-electric hospital bed. Our reviewer says that the semi-electric hospital bed is not medically reasonable and necessary. Our physician reviewer found you are an 88-year-old female diagnosed with epilepsy, seizure disorder, and vascular dementia who wants a semi-electric hospital bed for risk of falls. The documentation does not clearly reveal your condition has failed positioning of the bed in ways not feasible in an ordinary bed or why positioning of the bed in other ways is not feasible. The documentation does not support a need for an immediate or frequent changes in body position or special attachments that cannot be fixed on an ordinary bed.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a semi-electric hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve a semi-electric hospital bed (E0260).
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve right implant removal with mastopexy.
You asked the Plan to pre-approve the right sided procedure. You say that you have pain that affects your entire chest and just removing one implant would not be sufficient especially due to the recall. The Plan denied your request. The Plan says that there are only issues documented with the left side breast implant. There is no documented reason to remove the right implant.
The Plan follows Medicare rules. Medicare rules say that removal of breast implants is considered reasonable and necessary for the treatment of infection. 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 right sided procedure. Our reviewer says that the requested bilateral surgery is considered reasonable and necessary in this case. Our physician reviewer found that the enrollee has had infection. The local coverage determination indicates that treatment of infection is a covered service. The Food and Drug Administration has issued a recall on the device and recommended that symptomatic patients who are having symptoms such as lumps, pain, swelling, or asymmetry speak to their provider. The provider has documented the treatment to be bilateral removal. The elements of the coverage rule are satisfied. 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 right sided procedure have been met. Therefore, we decided that the Plan has to pre-approve right implant removal with mastopexy.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA).
You asked the Plan to pre-approve radiofrequency ablation. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
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 radiofrequency ablation. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has chronic neck, head and shoulder pain. The enrollee is taking Norco for pain. The enrollee underwent diagnostic right C3-C4 and C4-C5 medial branch blocks and obtained 100% pain relief. The enrollee underwent a right cervical RFA which produced 80% pain relief. The documentation submitted to review does NOT address a prior LEFT cervical RFA or diagnostic LEFT cervical medial branch blocks. Therefore, the enrollee does not meet criteria for the requested services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on September 11, 2020 by an out of network (OON) provider.
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says these services were provided by an out-of-network provider. The Plan says that prior authorization was not obtained by the member's primary care physician.
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 had network providers available who could have provided 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 physician services provided on September 11, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the determination of refractive state (92015) provided November 9, 2020.
You asked the Plan to pay for the refraction. You say that the service should be covered. The Plan denied your request. The Plan says the service was not performed as part of a routine eye exam and therefore is not covered.
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 performed during a routine exam by one of the Plan's vision vendor's Routine Vision Care Providers. We looked at the file and the Plan's rules. The refraction was not performed as part of a routine exam. Based on this information, we decided that the Plan's rules for coverage of the refraction have not been met. Therefore, we decided that the Plan does not have to pay for the determination of refractive state (92015) provided November 9, 2020.
Your complaint about whether the provider is part of the third-party vendor's routine vision care network 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the complete upper denture provided on October
19, 2020.

You asked the Plan to reimburse you for the dental item. You say that according to your Summary of Benefits,
dentures are covered. You say that you picked this policy and company for this sole reason. You say that you
have waited 3 years since receiving chemotherapy to have teeth again. You also say that you still need to get
bottom ones too. The Plan denied your request. The Plan says complete upper denture is not listed as a covered
item. The Plan also says that there is no record indicating that you contacted the Plan to verify benefits and
provider eligibility.

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 complete upper denture is not
among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for
the complete upper denture provided on October 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on December 17, 2020 by an out of network (OON) provider.

You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.

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 had network providers available who could have provided 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 physician services provided on December 17, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for infusion services (S9328) provided September 1, 2020 to October 8, 2020.

You asked the Plan to pay for the infusion services. You say that the services were medically necessary. The Plan denied your request. The Plan says this is not a covered service.

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 find that CPT code S9328 is not supported in the medical record. Specifically, per the CMS National Physician Fee Schedule, the code has a status of "I" which means it is not valid for Medicare payment. Based on this information, we decided that Medicare rules for coverage of the infusion services have not been met. Therefore, we decided that the Plan does not have to pay for infusion services (S9328) provided September 1, 2020 to October 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided October 3, 2020.
You asked the Plan to pay for the lumbar-sacral orthosis. You say that the item provided was medically necessary. The Plan denied your request. The Plan says the patient did not receive video or telephonic visit by the ordering physician in order to warrant the code billed.
The Plan follows Medicare rules. Medicare rules say that a spinal orthosis is subject to the criteria listed in the Medicare rules section. 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 lumbar-sacral orthosis. Our reviewer says that the item provided was not medically reasonable and necessary. Our physician reviewer found an appropriate history and a physical examination of the back would reasonably be required to adequately assess whether the coverage criteria for an LSO have been met. The documentation does not support that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as there is insufficient documentation of an appropriate evaluation and a credible physical examination of the back.
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 lumbar-sacral orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided October 3, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy provided on October 14,
2020.
You asked the Plan to waive the copayment for the colonoscopy. You say that you would not have done the
procedure if you knew the cost. The Plan denied your request. The Plan says the copayment 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 $300
copayment for surgery services at an in-network outpatient hospital.
You have been asked to pay a $300 copayment for the colonoscopy. The colonoscopy falls within the
"Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical
centers" benefit category. The records show a biopsy was performed which is considered a surgical procedure.
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 colonoscopy provided on October 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam CT capture and interpretation (D0367) provided from October 77, 2020, to October 16, 2020.
You asked the Plan to pay for the cone beam CT capture and interpretation. You say that you have $3,000 for comprehensive dental services. You say that you need this service because your teeth do not resist another arrangement. You also say that you need the crowns. The Plan denied your request. The Plan says the cone beam CT capture and interpretation is not listed as a covered service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the 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 cone beam CT capture and interpretation (D0367) provided from October 77, 2020, to October 16, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81201, 81298, 81317, 81321, 81403, 81404) provided December 11, 2019.

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says rules for coverage have not been met.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. 

The services at issue in this appeal, genetic testing, was requested solely for screening purposes. The record shows no personal history of Cancer. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for lab services (81201, 81298, 81317, 81321, 81403, 81404) provided December 11, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ambulance transport (A0425, A0427) provided January 14, 2021.

You asked the Plan to waive the copayment for the ambulance transport. You say that the copayment should be waived due to COVID-19. The Plan denied your request. The Plan says there is no modification to ambulance copayments due to COVID-19 at this time. The correct amount was applied.

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 $250 copayment for Ambulance services. 

You have been asked to pay a $250 copayment for the ambulance transport. The ambulance transport falls 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 an ambulance transport (A0425, A0427) provided January 14, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to reduce the coinsurance for the vedolizumab injection provided on November 11, 2020.
You asked the Plan to reduce the coinsurance for the vedolizumab injection. You say that in 2018 and 2019 the maximum copayment for this service was $250. You say that you are requesting a reduction of the copayment. The Plan denied your request. The Plan says the claim reprocessed to only apply 20% coinsurance for the injection.
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 chemotherapy drugs and 20% coinsurance for all other drugs covered under Medicare Part B from an in-network provider. You have been asked to pay $1,218 which is 20% of the allowed amount for the vedolizumab injection. The allowed amount is $6,090 (20% x $6,090 = $1,218). The vedolizumab injection falls within the "Medicare Part B prescription drugs" 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 reduce the coinsurance for the vedolizumab injection provided on November 11, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for infectious agent detection by nucleic acid (DNA or RNA) (CPT code 87633) provided on November 16, 2020, by a non-participating provider.
You asked the Plan to pay for the laboratory services. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says the Medicare guidelines specifically list CPT code 87633 as non-covered.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. The Medicare guidelines specifically list CPT code 87633 as non-covered. Therefore, we decided that the Plan does not have to pay for infectious agent detection by nucleic acid (DNA or RNA) (CPT code 87633) provided on November 16, 2020, by a non-participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical extraction (D7210), the placement of an implant body (D6010), the initial 15 minutes of intravenous (IV) sedation (D9239), and the additional 15 minutes of IV sedation (D9243) provided on November 12, 2020.
You asked the Plan to pay for the dental services. You say that there are not many dental surgeons in your area. You say that your general dentist said that this provider has the highest rating for non-failure in dental implants. You say that you were referred by a "Medicare provider" for the services. You also say that you should be reimbursed the remaining amount of your maximum coverage, $400. The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan also says that payment cannot be made for dental services that you receive from a provider who has opted out of Medicare.
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 could be covered, the requested items or services are not among those covered under this benefit when you receive them from a provider who has opted out of Medicare. Therefore, we decided that the Plan does not have to pay for the
surgical extraction (D7210), the placement of an implant body (D6010), the initial 15 minutes of intravenous (IV) sedation (D9239), and the additional 15 minutes of IV sedation (D9243) provided on November 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for orthoses (L1833, L2397) provided October 8, 2020.

You asked the Plan to pay for the orthoses. You say that the items were medically necessary. The Plan denied your request. The Plan says the documentation does not support the items 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 find that CPT codes L1833, & L2397 are not supported in the medical record. Specifically, the plan record shows no claim showing the patient received a video or telephonic visit by the ordering physician in order to warrant the codes billed. Based on this information, we decided that Medicare rules for coverage of the orthoses have not been met. Therefore, we decided that the Plan does not have to pay for orthoses (L1833, L2397) provided October 8, 2020.