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

We decided that the Plan does not have to pay forthe drug testing rendered on September 19, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay forthe drug testing rendered on September 19, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for cerebral perfusion analysis using computed tomography (0042T) provided August 22, 2019.You asked the Plan to pay for the cerebral perfusion analysis. You say that the services were medically necessary.The Plan denied your request. The Plan says the service at issue is not a covered benefit.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 0042T is not supported in the medical record. Specifically, code 0042T is considered a non-covered service under Medicare rules. Based on this information, we decided that Medicare rules for coverage of the cerebral perfusion analysis have not been met.Therefore, we decided that the Plan does not have to pay for cerebral perfusion analysis using computed tomography (0042T) provided August 22, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete maxillary denture.You asked the Plan to pre-approvethe complete maxillary denture. You say that the enrollee's current upper denture is broken and chipped on the arch. You also say that without a new denture, the enrollee will not be able to eat and sustain a healthy life.The Plan denied your request. The Plan says this service exceeds the maximum count allowed per period.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, complete dentures are limited to one procedure every five years. The record shows that you received a complete denture on June 1, 2017 and the enrollee's complete dentures benefit is now exhausted.Therefore, we decided that the Plan does not have to pre-approvea complete maxillary denture.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe knee orthosis and the wrist hand orthosis provided on August 30, 2019.
You asked the Plan to pay forthe knee orthosis (L1851) and the wrist hand orthosis (L3916). You say that the orthoses were medically necessary.The Plan denied your request. The Plan says criteria for the orthoses was not met.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 knee orthosis (L1851) and the wrist hand orthosis (L3916). Our physician reviewer found the enrollee's chief complaint was chronic pain located in the following location(s): Knee Right and Wrist Right. The documentation in the case file does not support that the requested knee orthoses with sleeves were medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. There is insufficient credible objective documentation of knee joint laxity. The item coded L2397 (sleeve) is not separately payable when the base item is not covered.The documentation in the case file does not support that the requested wrist/hand orthosis was medically reasonable and necessary for the enrollee in this case. An appropriate history and a physical examination of the wrist would reasonably be required to adequately assess whether the wrist/hand orthosis was medically reasonable and necessary. The documentation does not support that the wrist/hand orthoses were medically reasonable and necessary in this case, as there is no documentation of a credible physical examination of the wristsWe looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the knee orthosis (L1851) and the wrist hand orthosis (L3916) have not been met.Therefore, we decided that the Plan does not have to pay forthe knee orthosis and the wrist hand orthosis provided on August 30, 2019.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Planhas to pre-approvea porcelain crown (D2740) for tooth # 15, and a maxillary partial denture (D5211) for teeth # 6 through 12.You asked the Plan to pre-approvethe dental services. The Plan denied your request. The Plan says that that the crown and partial denture are not medically necessary as there were no x-rays submitted.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 indenying the request to pre-approve the dental services. Our reviewer says that the dental services meet the criteria for coverage. Our physician reviewer found the enrollee's dental record and radiographs indicates the need for a crown to replace the defective restoration in tooth #15. The replacement of the broken down teeth # 6 through 12 with a removable partial denture is reasonable and necessary. Additionally, based on the radiographs provided, the criteria for coverage for a crown on tooth #15 due tothe large defective restoration and a maxillary removable partial, denture to replace teeth # 6 through 12 have been met.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 been met.Therefore, we decided that the Plan has to pre-approvea porcelain crown (D2740) for tooth # 15, and a maxillary partial denture (D5211) for teeth # 6 through 12.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve complete invitro fertilization (S4015) and invitro fertilization procedure (S4021) for the enrollee.You asked the Plan to pre-approvecomplete invitro fertilization (S4015) and invitro fertilization procedure (S4021). You say that these procedures are necessary for the enrollee.The Plan denied your request. The Plan says complete invitro fertilization (S4015) and invitrofertilization procedure (S4021) cannot be covered as requested. The Plan must follow Medicare rules. Medicare requires providers to use Medicare appropriate codes. Codes with a status indicator of "S" are not approved or paid for Medicare recipients. Therefore, we decided that the Plan does not have to pre-approvecomplete invitro fertilization (S4015) and invitro fertilization procedure (S4021) for the enrolleeas requested.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided July 3, 2019 to August 12, 2019.You asked the Plan to pay for the SNF services. You say that you paid $8,371.39 to meet your required deductible and an additional $15,200.00 for the final four weeks of care denied by the plan and you would like reimbursement for this expense.The Plan denied your request. The Plan says the claim paid correctly and the correct coinsurance was appliedThe 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 40% coinsurance forout of networkSkilled nursing facility (SNF) care. You have been asked to pay $6,105.63. Per the EOC services rendered by an out of network SNF have amember responsibility of 40% coinsurance. The SNF services falls within the Skilled nursing facility (SNF) 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 pay forthe skilled nursing facility (SNF) services provided July 3, 2019 to August 12, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical nutrition therapy services (97802) for the 2019 benefit year.You asked the Plan to pay for medical nutrition therapy services. You say that you put the claim in as wellness allowance not as a medical claim. Nutritional counseling is allowed and you feel that the reimbursement should be processed The Plan denied your request. The Plan says this service does not qualify as a nutritional counseling course and is not a covered benefit.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. Records do not show that you suffer from renal disease or diabetes.Therefore, we decided that the Plan does not have to pay for the medical nutrition therapy services (97802) for the 2019 benefit year.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe health club membership for the 2018 benefit year.You asked the Plan to pay forthe health club membership. You say that in past years you submitted past the March 31 date and submitted for the full 12 months and stillgot reimbursed.The Plan denied your request. The Plan says the 2018 reimbursement request was not received in the required time frame.The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers gym benefits only reimbursement requests must be received no later than March 31st of the following year.The Plan's rules for coverage of gym benefits have not been met because the 2018 reimbursement was submitted after the March 31st deadline..Therefore, we decided that the Plan does not have to pay forthe health club membership for the 2018 benefit year
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the pathology services rendered to enrollee on March 20, 2019.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 services are not covered.The Plan must follow Medicare rules. Medicare rules say that modifier -26 is required for separate payment of the PC of radiology services when furnished in a different payment locality than the TC.The provider submitted a claim for procedure code 88305 (Level IV surgical pathology) with modifier -26. The file does not show that the PC was rendered in a different locality than the code that has already been paid by the Plan.Therefore, we decided that the Plan does not have to pay for the pathology services rendered to enrollee on March 20, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthosis (L1851) and suspension sleeve (L2397)
provided on August 20, 2019.
You asked the Plan to pay for the orthoses. You say that the medical records provided support the necessity of
the services in dispute. The Plan denied your request. The Plan says there is no evidence of an established
relationship between the enrollee and the ordering physician and there is no evidence of a prior telehealth
service with the ordering physician as required per CMS guidelines.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services,
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for
telehealth services only if they are presented from an authorized originating site located in either a county
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located
in a rural census tract.
A review of the file does not show that the telehealth service was provided in an authorized originating site.
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute
for an in-person encounter. Consequently, the items/services ordered following the non-covered visit are
likewise non-covered. Therefore, we decided that the Plan does not have to pay for knee orthosis (L1851) and
suspension sleeve (L2397) provided on August 20, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the gradient compression glove.You asked the Plan to pre-approve the gradient compression glove. You say that you need the brace to help for swelling due to carpal tunnel.The Plan denied your request. The Plan says this item does not meet the definition of DME and is not covered under the plan benefits.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plan does not have to pre-approvethe gradient compression glove.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on September 25, 2019.You asked the Plan to pay for the orthoses. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay for the knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on September 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forlumbar-sacral orthosis (L0650) knee orthosis (L1851) and suspension sleeve (L2397) provided on July 9, 2019.You asked the Plan to pay forthe orthoses. You say that the medical records provided support the necessity of the services in dispute.The Plan denied your request. The Plan says there is no evidence of an established relationship between the enrollee and the ordering physician, there was no claims submitted for an evaluation and management service and there is no evidence of a prior telehealth service with the ordering physician as required per CMS guidelines.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the non-covered visit are likewise non-covered.Therefore, we decided that the Plan does not have to pay forlumbar-sacral orthosis (L0650) knee orthosis (L1851) and suspension sleeve (L2397) provided on July 9, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Repatha Sureclick (J3590).
You asked the Plan to pre-approve Repatha Sureclick. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee has a medical only policy which does not include Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been met.
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 Repatha Sureclick (J3590).
Benefits for Repatha Sureclick 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: ER
Decision: Unfavorable

We decided that the Plan does not have to pay foran emergency room visit (99284) provided on July 22, 2019.You asked the Plan to pay forthe physician services. You say that the services were medically necessary.The Plan denied your request. The Plan says documentation received shows that this code is duplicative of another claim already 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 99284 is not supported in the medical record. Specifically, a claim for an emergency roomvisit for the same thing was already submitted. Based on this information, we decided that Medicare rules for coverage of the physician services have not been met.Therefore, we decided that the Plan does not have to pay foran emergency room visit (99284) provided on July 22, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forarthrocentesis provided on August 8, 2019.You asked the Plan to waive the copayment forarthrocentesis. You say that you 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 $245 copayment for surgery services provided in an outpatient hospital facility. You received arthrocentesis on August 8, 2019. Arthrocentesis is considered an outpatient surgical procedure. Therefore, you are responsible to pay the allowed amount of $236.21, which is less than the $245 copayment. You have been asked to pay $236.21 for arthrocentesis. Arthrocentesis falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 forarthrocentesis provided on August 8, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided July 1, 2019 to July 30, 2019.You asked the Plan to pay for the SNF services. You say that you feel that the plan should cover for the SNF services.The Plan denied your request. The Plan says the 100 day SNF benefit is exhausted.The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone60 days in a row without inpatient hospital or SNF care. The file shows that you received 100 days of SNF care during the benefit period from March 14, 2019 to July 1, 2019. The Plan has covered 100 days of SNF care.Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. You will be eligible for a new benefit period when you have not been receiving care in a hospital or skilled care in a SNF for at least 60 days in a row.Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided July 1, 2019 to July 30, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe bitewings provided on August 29, 2019.You asked the Plan to pay forthe bitewings. You say that the multiple images are absolutely required during treatment due to modifications/healing of the tooth and bone as the process continues. You also say that limiting images to one time per year in a case like yours is absurd.The Plan denied your request. The Plan says this service exceeds the frequency limitation in the benefit plan.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, bitewings are limited to one set per plan year. The record shows that you received bitewings on August 8, 2019 and your bitewings benefit was then exhausted.Therefore, we decided that the Plan does not have to pay forthe bitewings provided on August 29, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an occlusal guard (D9945).
You asked the Plan to pre-approve the dental item. The Plan denied your request. The Plan says an occlusal guard is not 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 occlusal guard is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an occlusal guard (D9945).