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

We decided that the Plan does not have to pay for the laboratory services rendered on November 17, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim is a duplicate.

The Plan must follow Medicare rules. The 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. The file shows that the services at issue were previously paid by the Plan on a separate claim for the same date of service. 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 laboratory services rendered on November 17, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab services provided on March 11, 2021.

You asked the Plan to waive the copayment for lab services. You say that you disagree with the charges because you have never been charged for labs in the past. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 copayment for lab services for outpatient hospital services. 

You have been asked to pay the allowed amount of $41.32, which is less than the $45 copayment for lab services. Lab services fall within the outpatient hospital 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 lab services provided on March 11, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says this is considered experimental and investigational.

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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found current evidence based medical guideline and peer reviewed literature do not fully support the spinal decompression device procedure over the 'gold standard' of lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollee's medical condition. FDA indications include implantation of the Superion device at one or two adjacent lumbar levels in patients with moderate spinal stenosis in whom operative treatment is indicated at no more than two levels, from L1 to L5.

This enrollee has multiple degrees of spinal stenosis, many not at FDA indicated levels of "moderate" spinal stenosis (including both planned levels of implantation, L4-5 and L5-6.) FDA contraindications include scoliosis, obesity, and osteoporosis. These have not been adequately addressed in the medical records. There is no discussion of scoliosis of the lumbar spine, including the lack of documentation of an applicable Cobb angle. There is no discussion indicating that a DEXA scan has demonstrated the lack of significant osteoporosis in this enrollee. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for Vertiflex Superion interspinous device at L4-5 and L5-6 is not medically reasonable or necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive periodontal evaluation (D0180) provided on February 17, 2021.
You asked the Plan to pay for a comprehensive periodontal evaluation. You say that because you were a new patient the provider had to do an exam to evaluate the condition of your gums. The Plan denied your request. The Plan says the service at issue is not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.
Therefore, we decided that the Plan does not have to pay for a comprehensive periodontal evaluation (D0180) provided on February 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a powered upper extremity range of motion assist device.
You asked the Plan to pre-approve a powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all components and accessories, custom fabricated (L8702). You say that the device allows individuals to increase gross manual dexterity and may promote integration of bimanual and unilateral activities. The Plan denied your request. The Plan says peer reviewed literature considers the use of robotic therapy for upper and lower extremity stroke rehabilitation investigational in nature.
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 a powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all components and accessories, custom fabricated (L8702). Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found the MyoPro is not known to be effective, based on scientific evidence, professional standards and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not in widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long-term outcomes for this patient, improve hemiparetic arm function, or be safe for long term use. There is insufficient evidence in the literature that this device will increase participation in bimanual activities. 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 powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all components and accessories, custom fabricated (L8702) have not been met. Therefore, we decided that the Plan does not have to pre-approve a powered upper extremity range of motion assist device.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay more for the Lupron Depot provided on February 19, 2021.
You asked the Plan to pay more for the Lupron Depot. You say that the doctor ordered the Lupron from the pharmacy and administered the drug. You say that you were not reimbursed your out-of-pocket costs paid to the pharmacy under the Part B benefit. 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 Medicare Part B covered drugs from an in-network PCP's office, specialist's office or pharmacy.
You have been asked to pay $1,512.94 for the Lupron Depot.
Service
Allowed Amount
Coinsurance
Plan Paid
Member Liability
Lupron Depot
$7,654.69
20%
$6,051.75
$1,512.94
The Lupron Depot 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 pay more for the Lupron Depot provided on February 19, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapy services represented by code 97110 provided on September 9, 2020.
You asked the Plan to pay for code 97110. 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 as 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 code 97110 is not supported in the medical record. Specifically, the records indicate that the services were performed by a physical therapist assistant in a home health or hospice setting. There is a more appropriate code for the billed services provided in a home health setting. Therefore, we decided that the Plan does not have to pay for the therapy services represented by code 97110 provided on September 9, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve arthrodesis (22634), posterior segmental instrumentation (22842), allograft (20930), stereotactic computer-assisted procedure (61783) and an inpatient hospital stay for the enrollee.

You asked the Plan to pre-approve these services. You say that the enrollee is in extreme pain and needs this surgery covered. The Plan denied your request. The Plan says that these 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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The CT scan shows solid fusions at L2-4 levels. There is no severe stenosis and spinal instability has not been demonstrated at any level with flex-ext x-rays. Also, the records show that the patient is a daily smoker which is a contraindication to fusion surgery. Our physician reviewer found that the enrollee's condition does not meet criteria for these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve arthrodesis (22634), posterior segmental instrumentation (22842), allograft (20930), stereotactic computer-assisted procedure (61783) and an inpatient hospital stay for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from January 9, 2020, to January 14, 2020.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you received the bill over a year later and disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 copayment for days 1-5 for inpatient hospital care. You had an inpatient hospital stay from January 9, 2020, to January 14, 2020. Therefore, you are responsible to pay a $200 copayment for days 1-5 (January 9, 2020, to January 13, 2020). The total amount you owe is: $200
(copayment) x 5 (inpatient days) = $1,000. You have been asked to pay the total copayment amount of $1,000 for an inpatient hospital stay. An inpatient hospital stay 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 an inpatient hospital stay provided from January 9, 2020, to January 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hearing aids (V5253) to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve hearing aids. You say that you prefer the hearing aids offered by this provider. The Plan denied your request. The Plan says there are providers in-network who can provide the requested items and services.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when they are received from an in-network provider. 

We looked at the file and the Plan's rules. 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. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to pre-approve hearing aids (V5253) to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the fillings (D2392 x 2) provided on February 2, 2021.
You asked the Plan to pay more for the dental service. You say that the only work that you had done prior to this date of service is a cleaning. You say that that should not qualify as a frequency limit. You also say that the Plan only paid $24.50 for a $370 bill. The Plan denied your request. The Plan says 1 filling is covered per calendar year. The Plan says that fillings performed out of network have a 50% coinsurance. The Plan also says that out of network providers may bill you for any amount over what was paid to the provider.
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 fillings are listed as covered, the frequency limit has been reached. The record shows that the Plan paid the out of network rate for the filling for tooth #2. Additionally, out of network providers may bill you for any amount over what the plan paid.
Therefore, we decided that the Plan does not have to pay more for the fillings (D2392 x 2) provided on February 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional payment for the frames (V2020), progressive lenses (V2781) and polycarbonate lenses (V2784) provided March 23, 2021.

You asked the Plan to provide additional payment for the frames and lenses. You say that the eyewear is medically necessary and should be covered. The Plan denied your request. The Plan says your maximum allowance plus a discount has been applied to the routine eyewear purchase and no additional reimbursement is due.

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 up to a $100 routine eyewear benefit. 

We looked at the file and the Plan's rules. In this case the Plan provided documentation showing that the $100 benefit vision benefit was applied to the retail price of your routine eyewear. Your cost-share was less than or equal to the remaining amount over $100. Based on this information, we determined that the cost-sharing has been applied correctly. Therefore, we decided that the Plan does not have to provide additional payment for the frames (V2020), progressive lenses (V2781) and polycarbonate lenses (V2784) provided March 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the acupuncture services (97810, 97811, 97813, 97814) medical nutrition therapy (97803) infrared light therapy (97026) provided December 9, 2020 to December 29, 2020.
You asked the Plan to pay for the acupuncture, nutrition counseling and infrared therapy. You say that please see attached office notes. The Plan denied your request. The Plan says acupuncture services must be provided by a legally qualified physician and the records do not support the billed service. Infrared therapy is not covered.
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services only for enrollees with renal disease or diabetes. Medicare rules say that items and services that are not medically necessary are not covered. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case. We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, says acupuncture services must be provided by a legally qualified physician. The services were rendered by a licensed acupuncturist. The provider is not supervised by a physician, PA, NP or CNS. Infrared therapy is a non-covered service. CPT code 97803 to represent cupping. There is insufficient documentation to verify that this service was performed.
Therefore, we decided that the Plan does not have to pay for the acupuncture services (97810, 97811, 97813, 97814) medical nutrition therapy (97803) infrared light therapy (97026) provided December 9, 2020 to December 29, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound provided on September 21, 2020. 
You asked the Plan to waive the copayment for an ultrasound. You say that you received an email stating that all services were covered with no copayment through September 2020. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount. 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 copayment for ultrasounds.  
You received an ultrasound on September 21, 2020. Ultrasounds are not included in the COVID-19 waiver. Therefore, you are responsible to pay the $35 copayment.  
You have been asked to pay a $35 copayment for an ultrasound. An ultrasound falls 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 copayment for an ultrasound provided on September 21, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ezetimibe 10 mg tablet.

You asked the Plan to pre-approve Ezetimibe. You say that this request is medically necessary. The Plan denied your request. The Plan says this drug is not covered under the medical 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 Ezetimibe 10 mg tablet.

Benefits for Ezetimibe 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the positron emission tomography (PET) scan provided on April 9, 2021.
You asked the Plan to pay for the positron emission tomography (PET) scan. You say that you feel this claim should be paid. The Plan denied your request. The Plan says Medicare billing criteria are not met, as the diagnosis code used on the claim is not supported by the medical records.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate diagnosis and service codes that report the service billed to the highest degree of specificity. The claim itself was billed with a diagnosis code of "C50.911 defined as Malignant neoplasm of unspecified site of right female breast." However, the medical records provided indicate the right breast was the part of the body that was the area of concern and there was a more specified site. In this case, this claim cannot be paid as billed due to a generic diagnosis code and the omission of specific codes or modifiers that identify the exact part of the body requiring the image. If more areas of the body than the right breast required imaging, the claim should have reflected that with the appropriate codes being billed and submission of the appropriate medical record documentation. Medicare rules for coverage of this claim as billed have not been met. Therefore, we decided that the Plan does not have to pay for the positron emission tomography (PET) scan provided on April 9, 2021.