Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endodontic therapy for tooth 18.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are 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 pre-approve endodontic therapy for tooth 18.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the 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 services are not medically necessary. Our physician reviewer found the enrollee has spinal stenosis. The requested Superion spacer is considered experimental/investigational in nature, as more research is needed to show its safety and efficacy. The services are therefore not reasonable or 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 not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve custom foot orthotics.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.

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 the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve custom foot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services with dental codes D0120 and D4910.

You asked the Plan to pay for dental codes D0120 and D4910. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the exam with dental code D0120 is denied due to frequency. The Plan only covers one exam per calendar year and the records show the plan already covered an exam. The Plan says the periodontal maintenance with dental code D4910 was denied because it is not a covered benefit under your 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.

We looked at the file and the Plan's contract. The Plan covers dental exams once per calendar year. The file shows that the Plan had previously paid for a dental exam. Though the Plan offers a dental benefit in excess of Medicare coverage, dental code D4910 is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental services with dental codes D0120 and D4910.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the durable medical equipment (L0650).

You asked the Plan to pay for the durable medical equipment. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. 

The record does not contain a valid proof of delivery for the supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the durable medical equipment (L0650).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services (A0425, A0429) provided July 12, 2020.

You asked the Plan to pay for the ambulance services. You say that the services were medically necessary, The Plan denied your request. The Plan says these services are not separately 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. 

We find that CPT codes A0425 & A0429 are not supported in the medical record. Specifically, records show the enrollee was an inpatient when the ambulance services were provided. Payment is bundled with payment for the inpatient stay in this case. Based on this information, we decided that Medicare rules for coverage of the ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for ambulance services (A0425, A0429) provided July 12, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a 115-mile routine transportation trip.

You asked the Plan to pre-approve a 115-mile routine transportation trip. You say that you need this trip approved because providers in your area are not accepting new patients. The Plan denied your request. The Plan says the length of this trip exceeds your benefit.

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 routine transportation when each trip does not exceed 75 miles of driving distance. 

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve a 115-mile routine transportation trip.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the ConfirmMDx test (81551) provided on July 15, 2020.

You asked the Plan to pay for the ConfirmMDx test. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the enrollee does not meet criteria.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We looked at the file and Medicare rules. Medicare covers ConfirmMDx testing when a patient is being considered for a repeat biopsy due to persistent or elevated cancer-risk factors. The case file does not show that the enrollee was being considered for a repeat biopsy. Based on this information, we decided that Medicare rules for coverage of the ConfirmMDx test have not been met. Therefore, we decided that the Plan does not have to pay for the ConfirmMDx test (81551) provided on July 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital services provided July 31, 2020.

You asked the Plan to pay for the hospital services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services are not eligible for separate 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. 

We find that the billed services are not supported. Specifically, payment for these services were bundled with the hospital stay. Based on this information, we decided that Medicare rules for coverage of the hospital services have not been met. Therefore, we decided that the Plan does not have to pay for hospital services provided July 31, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 77003 provided on July 21, 2020.

You asked the Plan to pay for CPT code 77003. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that CPT code 77003 has a bundled relationship with codes 61050, 61055, 62267, 62273, 62280, 62281, 62282, 62284, 64449, 64510, 64517, 64520, 64610, and 96450 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for CPT code 77003 provided on July 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve consultation with a neurosurgeon to be provided out of area (OOA).

You asked the Plan to pre-approve the OOA neurosurgery consultation. You say that the enrollee should be allowed to consult with a surgeon while OOA since conservative management of his condition has failed. The Plan denied your request. The Plan says this is not considered urgently needed. It can be delayed until returning to the service area, or the enrollee can use his out of network benefit to be seen by this provider.

Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care. 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 OOA neurosurgery consultation. Our reviewer says that the requested services are not considered urgently needed OOA care based on Medicare rules. Our physician reviewer found the patient reported right neck pain which radiates down the arm and hand and was associated with weakness in the hand and arm. He had failed physical therapy. He lives in Palm Springs, CA for the winter and requested seeing a neurosurgeon there due to ongoing pain and dysfunction. Based on the enrollee's presenting symptoms and findings, there is no need for immediate surgical intervention. It is medically reasonable to delay surgical consultation until the enrollee returns to the service area. 

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 OOA neurosurgery consultation have not been met. Therefore, we decided that the Plan does not have to pre-approve consultation with a neurosurgeon to be provided out of area (OOA).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit evaluation and management services (99350) provided by an out of network (OON) provider.

You asked the Plan to pay for the home visit. You say that you are requesting reconsideration due to covid-19 restrictions. Authorization should not be needed under telemedicine for payment of services rendered. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

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 the home visit evaluation and management services (99350) provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuromuscular stimulator, electric shock unit (E0745).

You asked the Plan to pay for this item. You say that the neuromuscular stimulator was medically necessary for the enrollee. The Plan denied your request. The Plan says the documentation provided indicates that the item at issue was not necessary for the 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 pay for this item. Our reviewer says that the neuromuscular stimulator is not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee had a chief complaint of knee pain. Diagnoses of primary osteoarthritis, pain, and chronic instability of the right and left knees, and muscle wasting and atrophy of the right and left lower legs are listed in the exam notes. A physical examination of the lower extremities would reasonably be required to adequately assess whether coverage criteria were met. The documentation does not support that the neuromuscular stimulator was medically reasonable and necessary in this case as there is insufficient documentation of a credible physical examination.

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 item have not been met. Therefore, we decided that the Plan does not have to pay for the neuromuscular stimulator, electric shock unit (E0745).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit with a specialist (99203) provided on October 29, 2020.

You asked the Plan to waive the copayment for the office visit. You say that you felt the provider was discriminatory to you due to a medical condition, and you should not have to pay this copayment because the provider refused to treat you. The Plan denied your request. The Plan says you were seen by the provider and office visits with a specialist have a $30 copayment.

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 $30 copayment for an office visit with a specialist. 

You have been asked to pay a $30 copayment for the office visit. Medical records show that the specialist was unwilling to provide your preferred treatment, but you did have an examination and consultation with the provider. An office visit with a specialist falls within the physician and practitioner 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 the office visit with a specialist (99203) provided on October 29, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (G0483) provided April 1, 2020.

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 the documentation does not support the services 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 code G0483 is not supported in the medical record. Specifically, the place of service listed on the claim (POS 11) does not match the place of service documented in the records (POS 57). Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (G0483) provided April 1, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the debridement.

You asked the Plan to waive the copayment for the debridement. You say that you did not have debridement on your foot. You say the doctor looked at your foot from across the room and wrote a prescription for orthopedic shoes. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $250 copayment per visit for Medicare-covered in-network ambulatory surgical center and in-network outpatient hospital facility visits.

You have been asked to pay a $250 copayment for the debridement. The debridement falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The medical record shows the doctor debrided the ulcer.

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 debridement.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist visit provided on July 30, 2020.

You asked the Plan to waive the copayment for the specialist visit. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received services provided by a specialist on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.

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 specialist visits. 

We looked at the file, the Plan's contract and Medicare rules. The file shows that you received services provided by a specialist on July 30, 2020. You have been asked to pay a $45 copayment for the specialist visit. The specialist visit falls within the Physician/Practitioner 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 the specialist visit provided on July 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner services provided on October 15, 2020.

You asked the Plan to pay for the nurse practitioner services. The Plan denied your request. The Plan says an authorization is required for services with an out-of-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 services at issue. 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 nurse practitioner services provided on October 15, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation service (A0425, A0429) provided on July 19, 2020.

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.

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 $265 copayment per date of service, for out-of-network emergent ambulance services, regardless of the number of trips. 

You have been asked to pay a $265 copayment for the out-of-network, emergent ambulance service provided. 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 ambulance transportation service (A0425, A0429) provided on July 19, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance transportation.

You asked the Plan to waive the copayment for ambulance transport. You say that you are requesting that the Plan take care of this bill. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.

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 $250 copayment for ambulance transport. 

You have been asked to pay $250 copayment for ambulance transport. 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 ambulance transportation.