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

We decided that the Plan does not have to pay for an anterior vestibuloplasty (40840) provided on January 8, 2020.
You asked the Plan to pay for an anterior vestibuloplasty. You say that this was a medical service. The Plan denied your request. The Plan says this was a non-covered dental service.
Medicare generally does not cover dental services. The Plan follows the same rule.
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 an anterior vestibuloplasty. Our reviewer says that the service in question is not covered under Medicare rules. Our physician reviewer found that procedure was done in connection to the care of structures directly supporting the teeth. The service is deigned to reshape the area of the gums around the residual bony ridge in order to make the situation more favorable for denture fabrication/use. The treatment is focused on treating the residual bony ridge that used to support the teeth, and the tissues that cover the ridges. There is nothing in the provided record that indicate that the service was integral to a medical service that would be considered covered such as removal of an underlying neoplasm. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for an anterior vestibuloplasty (40840) provided on January 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 30, 2019 to
January 2, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the subsequent nursing facility care (99309). You say that you would like
reconsideration because it is the responsibility of the facility to obtain authorization. The Plan denied your
request. The Plan says this provider is not in network and there is no authorization on file.
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 has network providers
available who can provide 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 medical services provided on December 30,
2019 to January 2, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on December 11, 2019.
You asked the Plan to pay for the services provided. You say that the codes are supported by the physician's custom profile. The Plan denied your request. The Plan says documentation did not contain evidence of a relationship with the ordering physician.
The Plan must follow Medicare rules. Medicare rules say that diagnostic tests must be ordered by the physician who is treating the beneficiary We looked at the file and Medicare rules. In this case, there were insufficient records to show the ordering physician is treating the enrollee for a specific medical problem. Based on this information, we decided that Medicare rules for coverage of have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on December 11, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on December 17, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 has network providers available who can provide the services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-network provider on December 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on August 2, 2019.
You asked the Plan to pay for the lumbar-sacral orthosis (L0650). You say that the Plan should pay this claim.
The Plan denied your request. The Plan says the physician order is invalid.
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 ordered following the noncovered visit are likewise
noncovered. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis provided
on August 2, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for vision services provided on January 13, 2020.
You asked the Plan to waive the copayment for the vision services. You say that you would like reconsideration because you should not have to pay out of pocket for services that were not received. The Plan denied your request. The Plan says you may reach out to request to be seen by an alternative ophthalmologist for a second opinion.
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 $25 copayment for Vision Care. You have been asked to pay a $25 copayment for the vision services. the vision services fall within the Vision Care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for vision services provided on January 13, 2020.
MAXIMUS Federal Services read your letter and knows that you may have a quality of care concern. MAXIMUS Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement Organization for further review.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the closed treatment of fracture services coded 28515
You asked the Plan to pay for the closed treatment of fracture services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed 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. In this case, the CPT Code Manual definition of code 28515 is closed treatment of fracture, phalanx or phalanges, other than great toe; with manipulation, each. We find that CPT code 28515 is not supported in the medical record. Specifically, the documentation submitted did not include documentation that closed treatment of fracture, phalanx or phalanges, other than great toe; with manipulation, each was performed. Based on this information, we decided that Medicare rules for coverage of the closed treatment of fracture services have not been met. Therefore, we decided that the Plan does not have to pay for the closed treatment of fracture services coded 28515
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on October 31, 2019.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
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 test at issue in this appeal, the laboratory services, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on October 31, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on November 16, 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 testing is not covered.
The Plan must follow Medicare rules. The rules say that MolDX will reimburse approved tests. The test at issue was not approved through the MolDx program for the date of service at issue. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on November 16, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the mandibular partial denture and maxillary partial denture provided on December 27, 2019.
You asked the Plan to pay for the mandibular and maxillary partial dentures. You say that you were not informed of the cost of the dentures at the time of the service. You also say that you are on a fixed income. The Plan denied your request. The Plan says the dental maximum benefit had been met.
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 Plan offers a $1,000 annual dental benefit maximum. The record shows that you met the annual maximum benefit on December 27, 2019 and your annual maximum benefit had been exhausted. The Plan also confirmed that you were informed that you had a $1,000 annual maximum during your call on August 15, 2019. Therefore, we decided that the Plan does not have to pay for the mandibular partial denture and maxillary partial denture provided on December 27, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMEMS HF system.
You asked the Plan to pre-approve a CardioMEMS HF system. You say that the requested CardioMEMS HF
system is medically necessary. The Plan denied your request. The Plan says the requested CardioMEMS HF
system is 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 a CardioMEMS HF system. Our
reviewer says that the requested CardioMEMS HF system is not medically necessary. Our physician reviewer
found the enrollee is with a history of hypertension, hyperlipidemia, diabetes, obstructive sleep apnea, cor
pulmonale, anemia and NYSHA Class III congestive heart failure with preserved ejection fraction (LVEF 65%)
requiring hospitalization.
In this circumstance therapy change based on data obtained from a CardioMEMS device has been
demonstrated in only one trial to help reduce hospital readmission compared to standard medical therapy.
Moreover, concerns have been raised about potential bias in this trial calling into question the results.
Therefore, the efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and
not recommended in current guidelines for the treatment of heart failure. Medicare coverage criteria are not met
since the device should still be considered experimental or investigational.
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 CardioMEMS HF system have not been met. Therefore, we decided that the
Plan does not have to pre-approve a CardioMEMS HF system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power operated vehicle (POV).
You asked the Plan to pre-approve a POV. You say that the requested POV is medically necessary. The Plan
denied your request. The Plan says the requested POV 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 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 POV. Our reviewer says that the
requested POV does not meet criteria. Our physician reviewer found the enrollee uses a manual wheelchair for
mobility and is supervised for activities of daily living. He cannot drive or utilize public transportation. The
member has impaired mobility.
In this case, the enrollee is not noted to have inability to utilize a lesser device (lightweight manual wheelchair,
or a standard manual wheelchair, which the enrollee already has). Therefore, this request is not medically
necessary. There is no covered indication.
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 POV have not been met. Therefore, we decided that the Plan does not have to
pre-approve a power operated vehicle (POV).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care services provided by a participating facility on October 4, 2019.
You asked the Plan to waive the copayment for emergency care services. You say that you thought this would be covered. You say that you are on a fixed income. 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 $90 copayment for emergency care. You have been asked to pay a $90 copayment for emergency care services. Since emergency care services were provided, the correct copayment has been applied. Emergency care services fall within the emergency care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for emergency care services provided by a participating facility on October 4, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 76700) provided on November 21, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that for enrollees who are registered hospital inpatients or outpatients, the inpatient or outpatient hospital POS code should be reported. We looked at the file and Medicare rules. The services in question were billed with an outpatient place of service (POS 22). As the enrollee was under inpatient status when the services were provided, it is inappropriate to bill an outpatient POS code. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services (CPT 76700) provided on November 21, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for breast reconstruction (19364) provided on June 10, 2019.
You asked the Plan to pay for breast reconstruction. You say that this should be covered. The Plan denied your request. The Plan says this code was not documented in the narrative of the operative report.
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 19364 is breast reconstruction with free flap. 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 breast reconstruction. Our reviewer says that this code is not supported. Our physician reviewer found a breast reconstruction with free flap was not documented in the operative report. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of breast reconstruction have not been met. Therefore, we decided that the Plan does not have to pay for breast reconstruction (19364) provided on June 10, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for an abdominal procedure (4999) provided on November 5,
2019.
You asked the Plan to pay for the abdominal procedure. You say that you would like reconsideration based on
the records submitted. The Plan denied your request. The Plan says the report did not include documentation of
an unlisted 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 49999 is unlisted procedure, abdomen, peritoneum and
omentum.
We asked our coder 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 abdominal procedure. Our reviewer says that CPT code
4999 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records
provided does not include documentation specifically indicating the use of procedure code 49999, therefore this
service cannot be verified. The operative report does not include documentation of the requisite anatomic
reconstructive indication, technical criteria, and all components of the creation of an omental flap or a falciform
ligament flap.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the abdominal procedure have not been met. Therefore, we decided that the
Plan does not have to pay for an abdominal procedure (4999) provided on November 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous glucose monitor supplies provided to the enrollee on September 4, 2019.
You asked the Plan to pay for the supplies. The Plan denied your request. The Plan says that the billed services were not supported.
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 shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The date of service provided is not is not the same date the shipping label was created. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor supplies provided to the enrollee on September 4, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded 80307 and G0480 provided on December 13, 2019.
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed 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 80307 and G0480 are not supported in the medical record. Specifically, the documentation does not support any evidence of an established relationship between the enrollee and the ordering physician. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded 80307 and G0480 provided on December 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient services provided on January 30, 2020 by an out
of network (OON) provider.
You asked the Plan to pay for outpatient services. You say that you would like this claim reprocessed and
approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained.
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 has network providers
available who can provide 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 outpatient services provided on January 30, 2020
by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four monitoring (95999) provided on October 16, 2019.
You asked the Plan to pay for the train of four monitoring. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says train of four is considered a bundled procedure and payment for it is included in payment for the already-approved neuromonitoring.
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 95999 is not supported in the record. Specifically, train of four monitoring is considered integral to the primary procedure. Payment for train of four is bundled into the payment for the primary neuromonitoring procedure. Based on this information, we decided that Medicare rules for coverage of the train of four monitoring have not been met. Therefore, we decided that the Plan does not have to pay for train of four monitoring (95999) provided on October 16, 2019.