Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for needle electromyography (95885) and needles (A4215) provided on July 16, 2020.
You asked the Plan to pay for needle electromyography and needles. You say that these services were billedd correctly. The Plan denied your request. The Plan says these codes are not payable 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. In this case, the CPT Code Manual definition of code 95885 needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; limited (List separately in addition to code for primary procedure) and A4215 needle, sterile, any size, each. We find that CPT codes 95885 and A4215 are not supported in the medical record. Specifically, 95885 was billed without an appropriate primary procedure (CPT codes 95907-95913), and A4215 represents supplies that are not separately billable from the services they are used for. Based on this information, we decided that Medicare rules for coverage of needle electromyography and needles have not been met. Therefore, we decided that the Plan does not have to pay for needle electromyography (95885) and needles (A4215) provided on July 16, 2020.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for the air ambulance transport rendered on August 9, 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 that the transport was not medically necessary.
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your medical condition is such that transportation by ground ambulance is not appropriate. 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 these services. Our reviewer says that the transport was medically necessary. Our physician reviewer found the enrollee had a fall at home and was found with a likely hip fracture as well as slurred speech. Her age of 85 years satisfies the criteria for a trauma alert. Based upon the available information at the scene, ground transportation was inappropriate due to potential for decompensation, and the length of the drive would remove the enrollee from access to emergency services. The air transport was therefore reasonable and medically 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 these services have been met. Therefore, we decided that the Plan has to pay for the air ambulance transport rendered on August 9, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to waive the copayment for an EKG provided on December 4, 2020.
You asked the Plan to waive the copayment for an EKG. You say that the device did not work properly. The Plan denied your request. The Plan says that the claims were processed correctly and the enrollee is 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). The enrollee's contract with the Plan says that enrollees must pay a $0 copayment for EKG's. The Plan says the enrollee must pay a $65 copayment for an EKG. Based on the plan contract, however, the enrollee cannot be asked to pay more than a $0 copayment for an EKG. Therefore, we decided that the Plan has to waive the copayment for an EKG provided on December 4, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on September 22, 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 September 22, 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 September 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the placement of an implant body (D6010) for tooth # 29. You asked the Plan to pre-approve the dental service. You say that this service was denied because it is only allowed every 36 months. You say that you have never had an implant before. The Plan denied your request. The Plan says the most cost-effective treatment for replacing your missing teeth must be approved. The Plan also says that a partial denture is the more cost-effective treatment to replace more than one missing tooth in the same part of your mouth. 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. The Plan covers the dental service when the services are medically necessary and reasonable. 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 dental service. Our reviewer says that the implant for tooth # 29 is not medically necessary. Our physician reviewer found the provided documentation shows that there are several missing lower teeth on each side of the lower arch. The reviewer found that the most cost effective method of restoring the mouth would be with the use of a partial lower denture. The reviewer found that a single tooth implant would be a costly alternative to replace a single tooth. The plan limitations would direct the choice of a restoration to a removable appliance in this type of situation. Given the Policy limitations for services related to the replacement of teeth, there would be no necessity found for a single tooth implant on #29 as requested. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental service have not been met. Therefore, we decided that the Plan does not have to pre-approve the placement of an implant body (D6010) for tooth # 29.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis coded L1833 and the addition coded L2397.

You asked the Plan to pay for the knee orthosis and the addition. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the items provided 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.

We find that CPT codes L1833 and L2397 are not supported in the medical record. Specifically, there is no documentation to support a face-to-face evaluation, physical examination, or imaging demonstrating medical necessity of the items provided.

Based on this information, we decided that Medicare rules for coverage of the knee orthosis and the addition have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis coded L1833 and the addition coded L2397.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for Cannibidiol (CBD) oil purchased July 13, 2020.
You asked the Plan to pay for the CBD oil. You say that your primary care provider suggested this will help you for your pain and you are requesting reconsideration for approval of this CBD oi. The Plan denied your request. The Plan says this item is a non-covered under the Flex Benefit. Although the plan covers some herbal remedies as referenced on the Flex Benefit eligible items list, CBD oil is not on the list.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the CBD oil is an OTC item. Therefore, we decided that the Plan does not have to pay for Cannibidiol (CBD) oil purchased July 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on June 18, 2020.

You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 did not pre-approve the physician's services. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on June 18, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient hospital services provided by a participating provider on September 1, 2020, to September 29, 2020.
You asked the Plan to waive the copayment for outpatient hospital services. You say that there was no minor surgery. You say that these charges are way too much. The Plan denied your request. The Plan says the correct copayment has been 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 $175 copayment for outpatient hospital services/surgery services. You have been asked to pay less than a $175 copayment for outpatient hospital services. The total amount you are being asked to pay is $666.25 which is less than your copayment amount of $1,050 ($175 x 6 visits = $1,050). Outpatient hospital services fall within the outpatient hospital services/surgery 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 outpatient hospital services provided by a participating provider on September 1, 2020, to September 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem-focused re-evaluation (D0170), gingivectomy or gingivoplasty (D4210) and bone replacement graft (D7953) provided from January 13, 2020 to January 27, 2020.
You asked the Plan to pay for these dental services. You say that these services were not cosmetic and are essential in allowing you to eat properly. The Plan denied your request. The Plan says these services are excluded from coverage by both Medicare and the Plan's supplemental dental 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 the problem-focused re-evaluation (D0170), gingivectomy or gingivoplasty (D4210) and bone replacement graft (D7953) provided from January 13, 2020 to January 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a raised toilet seat.
You asked the Plan to pre-approve a raised toilet seat. You say that you have lost the strength in your legs. The
Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered
because they are not primarily medical in nature.
While a raised toilet seat may be appropriate, neither the Plan nor Medicare offers coverage of this item.
Therefore, we decided that the Plan does not have to pre-approve a raised toilet seat.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient surgery services provided by an out-of-network provider on August 21, 2020.
You asked the Plan to pay for inpatient surgery services. You say that the services were medically necessary. You say that the claim should be reprocessed and paid. The Plan denied your request. The Plan says the provider is not in-network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan 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 inpatient surgery services provided by an out-of-network provider on August 21, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of an interspinous spacer device (Vertiflex).
You asked the Plan to pre-approve Vertiflex. You say that this treatment is considered safe and effective and is medically necessary for the enrollee. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because studies have not proven that Vertiflex is helpful for treatment of the enrollee's condition.
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 Vertiflex. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental. More research is needed to show the safety and efficacy of Vertiflex. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Vertiflex have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of an interspinous spacer device (Vertiflex).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve contouring of benign tumor of facial bone (21029) and the related anesthesia (00190).
You asked the Plan to pre-approve the dental services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the information submitted fails to meet medical necessity criteria.
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. The Plan covers the dental services when the services are medically necessary and reasonable. 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 dental services. Our reviewer says that the dental services are not medically necessary. Our physician reviewer found the provided documentation shows that the removal of the lesion and extractions of teeth #'s 18 and 19 met the criteria for coverage due to being related to a medical condition. The reviewer found that further bone recontouring appears to be related to planned dental procedures, such as denture construction or implant placement. Therefore, the reviewer found that the requested bone contouring 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 the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does not have to pre-approve contouring of benign tumor of facial bone (21029) and the related anesthesia (00190).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for transportation of portable x-ray equipment and personnel to home or nursing home (R0075) provided March 12, 2020.
You asked the Plan to pay for the portable x-ray services. You say that this service was rendered due to medical necessity. As a fixed office on wheels, outfitted with an x-ray suite, you met the requirement of transporting x-ray equipment to the location where services were performed. The Plan denied your request. The Plan says place of service (POS) inappropriate for procedure.
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 R0075 is transportation of portable x-ray equipment and personnel to home or nursing home, per trip to facility or location, more than one patient seen We find that CPT code R0075 is not supported in the medical record. Specifically, CPT code R0075 has a PC/TC indicator of three (3), for a technical component only code as defined in Medicare Claim Processing Manual Chapter 23, in the Physician Fee Schedule Payment Policy Indicator File Record Layout. CPT code R0075 is a technical component only code, and should be reported on a hospital setting. The enrollee was in a skilled nursing facility on March 12, 2020. The appropriate POS code for the interpretation (or PC) is the setting where the beneficiary received the TC service. Based on this information, we decided that Medicare rules for coverage of the portable x-ray services have not been met. Therefore, we decided that the Plan does not have to pay for transportation of portable x-ray equipment and personnel to home or nursing home (R0075) provided March 12, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan provided on September 9, 2020.
You asked the Plan to waive the copayment for a CT scan. You say that you were told that you would only owe a specialist copayment 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 $50 copayment for CT scans. You have been asked to pay a $50 copayment for a CT scan. A CT scan falls within the outpatient diagnostic tests and therapeutic service 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 a CT scan provided on September 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device (HFCWOD).

You asked the Plan to pre-approve a HFCWOD. You say that the requested HFCWOD is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for a HFCWOD.

The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.

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 HFCWOD. Our reviewer says that the enrollee does not meet criteria for a HFCWOD. Our physician reviewer found this enrollee has chronic obstructive pulmonary disease (COPD), which is not a Medicare covered diagnosis for this treatment. The enrollee does not have cystic fibrosis, bronchiectasis, or generalized neuromuscular disease. This treatment has not been shown to be beneficial in COPD. HFCWOD is not medically 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 a HFCWOD have not been met. Therefore, we decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device (HFCWOD).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics.

You asked the Plan to pay for foot orthotics. You say that you have had surgery for a torn plantar plate. 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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve physician services. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are neither emergent nor urgent to seek out-of-network care. The Plan says there are in-network providers available to the enrollee that can provide the services being requested.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve physician services to be provided by an out of network (OON) provider.