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

We decided that the Plan does not have to pay for the resin based composite (D2330) for tooth # 22 provided on October 21, 2020.
You asked the Plan to pay for the dental service. You say that your booklet for 2020 says you have $500 for dental work and you would be responsible for anything over that amount. You say that it also says there is no copayment. You say that you thought the plan would cover the additional $155 as you had not reached your $500 maximum. The Plan denied your request. The Plan says resin based composite is not listed as a covered service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the resin based composite (D2330) for tooth # 22 provided on October 21, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the x-ray provided on October 29, 2020.
You asked the Plan to waive the copayment for the x-ray. You say that this was a follow up visit and x-ray after surgery. You say that this was a continuation of treatment not a new medical condition. The Plan denied your request. The Plan says the copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 copayment for Medicare-covered x-ray services. You have been asked to pay a $20 copayment for the x-ray. The x-ray falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. There is no provision in the contract which indicates a copayment would be waived for a service performed as a follow-up to a surgical procedure. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the x-ray provided on October 29, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the Removal of (2 centimeters or greater) muscle growth of face and scalp (21014) provided October 14, 2020.
You asked the Plan to waive the copayment for the removal of muscle growth. You say that the cost is too high. The Plan denied your request. The Plan says the copayment was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $390 copayment for Medicare-covered surgery or other services provided to you at an ambulatory surgical center, including but not limited to hospital or other facility charges and physician or surgical charges. You have been asked to pay a $390 copayment for the removal of muscle growth. This service within the Outpatient Surgery and Other Medical 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 for the Removal of (2 centimeters or greater) muscle growth of face and scalp (21014) provided October 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for arch supports (L3040) and sole and heel wedges (L3420).

You asked the Plan to pay for arch supports and sole and heel wedges. You say that you have been using these items for several years now and need them. The Plan denied your request. The Plan says these items are 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 do not show that you not suffer from diabetic foot disease or that you 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 arch supports (L3040) and sole and heel wedges (L3420).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a revision bariatric surgery (43235, 43775).

You asked the Plan to pre-approve the bariatric surgery. You say that the surgery is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan follows Medicare rules. Medicare rules say that repeat bariatric surgery is generally not reasonable and necessary.

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 bariatric surgery. Our reviewer says that the repeat bariatric surgery is not medically necessary. Our physician reviewer found the provided documentation does not provide a sufficient medical rationale to establish reasonability and necessity of a repeat procedure under the clinical circumstances as described.

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 bariatric surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve a revision bariatric surgery (43235, 43775).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the lung function test.

You asked the Plan to waive the copayment for the lung function test. You say that you went in for your annual wellness exam and was not told you would have an additional charged for the lung test. The Plan denied your request. The Plan says you have been asked to pay 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 $20 copayment for in-network Medicare-covered outpatient diagnostic procedures or tests.

You have been asked to pay a $20 copayment for the lung function test. The lung function test falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The medical record shows the lung function test was administered in addition to the annual wellness visit.

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 lung function test.
Appeal type: Outpatient Mental Health
Decision: Favorable

We decided that the Plan has to pay for behavioral health services (CPT 90791 and CPT 90785) provided to the enrollee.

You asked the Plan to pay for the services. You say that the services should be reimbursed because they are medically necessary. The Plan denied your request. The Plan says that these services are not covered for these diagnoses.

The Plan must follow Medicare rules. Medicare rules say that services are covered if they are medically necessary.

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 services. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has tried a number of different therapies without much success. She was given different methods for sleep structuring sleep hygiene/restrictions and stimulus control. Based on review the records provided, the evaluation for sleep/insomnia control is considered medically necessary and reasonable as this enrollee is being evaluated and treated for DSM-V disorder.

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 services have been met. Therefore, we decided that the Plan has to pay for behavioral health services (CPT 90791 and CPT 90785) provided to the enrollee.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the medical eye exam provided on November 23, 2020.
You asked the Plan to waive the copayment for the medical eye exam. You say that the doctor did not take off the skin tag. The Plan denied your request. The Plan says you have been asked to pay 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 $30 copayment per Medicare-covered eye exam. You have been asked to pay a $30 copayment for the medical eye exam. The medical eye exam falls within the "Vision care" benefit category. The medical record shows a diagnosis of cysts of the left upper eyelid. 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 medical eye exam provided on November 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the power wheelchair accessories (E2377, E2313, E2311, E1012).

You asked the Plan to pre-approve the wheelchair accessories. You say that you would like the accessories to be reconsidered. The Plan denied your request. The Plan says the accessories are not medically necessary.

The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.

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 wheelchair accessories. Our reviewer says that the wheelchair accessories are not medically necessary. Our physician reviewer found the E2377 Expandable Controller and E2313 Expandable Controller Harness are not medically necessary per Local Coverage Article: Wheelchair Options/Accessories - Policy Article (A52504).

The documentation does not reveal that the patient requires other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-proportional input devices (e.g., sip and puff, head array, etc.) The patient does not need to operate 3 or more powered seating actuators through the drive control, a separate display (i.e., for alternate control devices),other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. The patient's functional ability of independence in feeding should be sufficient to control any power options through their own switches.

The requested E1012 Center Mount Power Elevating Leg rests is also not medically necessary. The patient was not approved for a reclining wheelchair. The documentation does not indicate that the patient has a cast or brace preventing 90 degree flexion at the knee or the patient is unable to have 90 degree flexion at the knee. The documentation does not reveal evidence of leg edema. The E1012 Power Elevating Leg rests is not medically necessary per Local Coverage Determination (LCD): Wheelchair Options/Accessories (L33792).

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 wheelchair accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve the power wheelchair accessories (E2377, E2313, E2311, E1012).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT scan provided on October 23, 2020.
You asked the Plan to waive the copayment for the CT scan. You say that you were charged in error since you have $0 copayment insurance. The Plan denied your request. The Plan says the claim reprocessed to only apply a $50 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 $50 copayment for Medicare-covered diagnostic radiology services such as CT, MRI, etc. You have been asked to pay a $50 copayment for the CT scan. The CT scan 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 the CT scan provided on October 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6534.

You asked the Plan to pre-approve the compression stockings. You say that the enrollee requires The Plan denied your request. The Plan says claims for gradient compression wraps used without a qualifying wound or when used for other non-qualifying conditions will be denied as statutorily non-covered.

The Plan must follow Medicare rules. The rules say that compression stockings described by code A6534 are noncovered because they do not meet the statutory definition of a surgical dressing. 

Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6534.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on August 5, 2020.
You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says prior authorization is required for this service.
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 psychotherapy 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 psychotherapy services provided on
August 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee scooter (E0118).

You asked the Plan to pre-approve a knee scooter. You say that you require it after knee surgery. The Plan denied your request. The Plan says this item is not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that knee scooters are not covered due to a lack of published clinical literature demonstrating safety and effectiveness.

While a knee scooter may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a knee scooter (E0118).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on August 25, 2020.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says screening tests are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab services provided on August 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic continuous glucose monitor supply allowance provided on November 22, 2020.
You asked the Plan to pay for the supply allowance for therapeutic continuous glucose monitor (K0553). You say that the supplies are medically necessary. The Plan denied your request. The Plan says the documentation submitted did not indicate the provider discussed the need for the billed supply code.
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 relevant medical records which support medical necessity for the supplies provided in this case. The office visit records do not show the provider mentioned or recommended a CGM or supplies.
The record shows that the Plan made several attempts to obtain the necessary documentation without success. The record does not show the enrollee performs blood glucose testing at least four times per day, uses insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Criteria is not met for a CGM. Therefore, we decided that the Plan does not have to pay for the therapeutic continuous glucose monitor supply allowance provided on November 22, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy (S9328).

You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration because this is not durable medical equipment and was not delivered to the member's home. The Plan denied your request. The Plan says Medicare uses another code for the reporting of, and payment for, these services.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

We find that CPT code S9328 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code S9328 has a status indicator of I. This means that CPT code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy (S9328).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on September 1, 2020.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says there is no evidence of an established relationship between the member and the ordering physician.
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a physician who has furnished a consultation or treats an enrollee for a specific medical problem. The file does not contain documentation of an established relationship between the enrollee and the ordering provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on September 1, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on June 30, 2020.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. We looked at the file and Medicare rules. The documentation submitted does not contain medical records from the non-contract provider. Without records, it cannot be determined that Medicare coverage criteria have been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on June 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on August 18, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.
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 August 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the unspecified preventive service (D1999) provided on December 1, 2020.
You asked the Plan to pay for the dental service. You say that this service should be covered. The Plan denied your request. The Plan says the unspecified preventive service is not listed as a covered service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the unspecified preventive service (D1999) provided on December 1, 2020.