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

We decided that the Plan does not have to pay for the wound care services described by current procedural terminology (CPT) code 15271 provided on November 5, 2020.
You asked the Plan to pay for CPT code 15271. You say that the medical records support the billing of CPT code 15271. The Plan denied your request. The Plan says the medical records do not support the billing of CPT code 15271.
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 15271 is Application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area. 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 CPT code 15271. Our reviewer says that the medical records do not support the billing of CPT code 15271. Our physician reviewer found CPT code 15271 has been submitted for payment for application of a skin graft to the scalp. At issue is whether CPT code 15271 for the enrollee is a covered service under Medicare rules. CPT 15271 is defined as application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area. In this case the enrollee underwent excision of a squamous cell carcinoma of the scalp and underwent skin graft application. CPT code 15271 was submitted. This code refers to grafting of trunk, arms and legs. The elements of the CPT code 15271 are not satisfied. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CPT code 15271 have not been met. Therefore, we decided that the Plan does not have to pay for the wound care services described by current procedural terminology (CPT) code 15271 provided on November 5, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the PET scan (78815) provided on January 4, 2021.
You asked the Plan to pay for the PET scan. 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 as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file, the Plan's contract and Medicare rules. We find that the PET scan is not supported as billed. Specifically, this PET scan was not billed with an appropriate diagnosis code per Medicare guidelines. Therefore, we decided that the Plan does not have to pay for the PET scan (78815) provided on January 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the prosthetic equipment provided July 23, 2020.
You asked the Plan to waive the cost share for the prosthetic equipment. You say that you believe you should not be responsible for this payment. The Plan denied your request. The Plan says the cost share has processed correctly in this case.
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% coinsurance for prosthetic devices and related supplies. You have been asked to pay a total cost share of $2102.72 for the prosthetic equipment ($10513.59 Medicare-allowed amount x 20% coinsurance). The items you received fall within the prosthetic devices and related supplies benefit category. Although the Plan originally denied coverage for the vacuum pump (L5781), the Plan has reprocessed this claim with the applicable coinsurance. 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 cost share for the prosthetic equipment provided July 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic pulpotomy (D3220) and drugs or medicaments dispensed in the office for home use (D9630) provided on June 3, 2020.
You asked the Plan to pay for the therapeutic pulpotomy and drugs or medicaments. You say that you would like these services covered. The Plan denied your request. The Plan says these services are not covered.
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 therapeutic pulpotomy (D3220) and drugs or medicaments dispensed in the office for home use (D9630) provided on June 3, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory services (84520, 82565) and the computed tomography (CT) scan of the thorax (71250) provided on October 14, 2020 and October 15, 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 services 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 $10 copayment for Medicare-covered laboratory tests. Additionally, you pay $250 per day for Medicare-covered diagnostic radiology services. You have been asked to pay $140.44 ($131.37 + $9.07) for the Medicare-covered diagnostic radiology and laboratory services provided. This is the Plan allowed amount for these services, which is less than the applicable copayments. 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 laboratory services (84520, 82565) and the computed tomography (CT) scan of the thorax (71250) provided on October 14, 2020 and October 15, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for operative management of an avulsion fracture of the right ischium after a motor vehicle collision. Medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a segmental pneumatic appliance (E0673) provided on August 18, 2020.

You asked the Plan to pay for a segmental pneumatic appliance. You say that the requested item is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.

The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0673) is a preventive service. 

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pay for a segmental pneumatic appliance (E0673) provided on August 18, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the abdominal aorta ultrasound (76706) provided on December 2, 2020.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the claim is not payable as you have exceeded the maximum benefit for this service.

The Plan must follow Medicare rules. Medicare rules say that a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles and coinsurance). 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have not been met. Specifically, the record shows that you received the same service on January 13, 2020. This service is allowed once per lifetime. The benefit for this screening was exhausted before the service at issue was provided. Therefore, we decided that the Plan does not have to pay for the abdominal aorta ultrasound (76706) provided on December 2, 2020.

Your complaint that you were advised by a Plan representative that this service did not have a coverage limit is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the diagnostic tests provided on September 22, 2020.
You asked the Plan to pay for the diagnostic tests. 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 as billed.
The Plan must follow Medicare rules. Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient. We looked at the file and Medicare rules. In this case, the file shows the enrollee received these services during an inpatient hospitalization. Payment for these services were included in the facility payment. Therefore, we decided that the Plan does not have to pay for the diagnostic tests provided on September 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee orthosis (L1843).

You asked the Plan to pre-approve a knee orthosis. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan follows Medicare rules. Medicare rules say that knee instability must be documented by examination of the beneficiary and objective description of joint laxity. 

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 knee orthosis. Our reviewer says that the services are not medically necessary. Our physician reviewer found in this case; the case file does not contain objective evidence of an examination by the ordering prescriber that documents knee instability. The elements of the coverage rule are not satisfied. The requested service cannot be recommended. 

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 knee orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve a knee orthosis (L1843).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for osteomyelitis, sepsis and diabetic foot ulcers. Medical problems are stable. There are no complex rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office or other outpatient visit for the evaluation and management of a new patient (99204) provided on November 25, 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). The enrollee's contract with the Plan clearly says that she must pay a $35 copayment for each specialist visit. 

The enrollee has been asked to pay a $35 copayment for the specialist visit provided. This means that she has been asked to pay the correct amount based on her contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay when she enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the office or other outpatient visit for the evaluation and management of a new patient (99204) provided on November 25, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on December
17, 2020.

You asked the Plan to waive the copayment for ambulance services. You say that the ambulance services
should have never been called and you disagree with the charges. The Plan denied your request. The Plan says
the claims were processed correctly and the enrollee is being charged the correct amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees
must pay a $250 copayment for ambulance services.

The enrollee has been asked to pay a $250 copayment for ambulance services. Ambulance services fall within
the ambulance services benefit category. This means that the enrollee has been asked to pay the correct amount
based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay
upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for
ambulance services provided on December 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397) provided July 22, 2020.
You asked the Plan to pay for the knee orthosis and suspension sleeve. You say that the requested items were medically necessary. The Plan denied your request. The Plan says the documentation is missing required information.
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. Review of the file shows that the proof of delivery did not include an itemize order form or invoice to indicate the specific supplies; therefore, the billed supply code cannot be verified. 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 knee orthosis (L1833) and suspension sleeve (L2397) provided July 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1833), suspension sleeve (L2397), ankle foot orthosis (L1971) and heel stabilizer (L3170) provided September 24, 2020.
You asked the Plan to pay for the knee orthosis, suspension sleeve, ankle foot orthosis, and heel stabilizer. You say that you would like these claims reprocessed for medical necessity. The Plan denied your request. The Plan says there was no evidence of an established relationship between the prescribing physician and the enrollee.
The Plan follows Medicare rules. Medicare rules say that the knee orthosis, suspension sleeve, ankle foot orthosis, and heel stabilizer are subject to the criteria listed in the Medicare rules section. 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, suspension sleeve, ankle foot orthosis, and heel stabilizer. Our reviewer says that the requested items were not medically reasonable and necessary. Our physician reviewer found the documentation in the case file does not support that the requested knee orthosis and sleeve were medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. There is no documentation of recent injury to, or recent surgical procedure on the enrollee's knee, there is insufficient documentation of an appropriate evaluation of the enrollee, with insufficient credible objective documentation of joint laxity. In addition, claims for L1833 will be denied as not reasonable and necessary when the beneficiary does not meet the criteria for coverage. Furthermore, the documentation in the case file does not support that the requested ankle/foot orthosis was medically reasonable and necessary for the enrollee in this case, according to the criteria established by the LCD. A physical examination of the ankle and foot would reasonably be required to adequately assess whether the coverage criteria were met. The documentation does not support that the ankle/foot orthosis was medically reasonable and necessary in this case, as there is insufficient documentation of a credible physical examination
of the ankle and foot. Likewise, the documentation does not support the medical necessity of a heel stabilizer. 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 knee orthosis, suspension sleeve, ankle foot orthosis, and heel stabilizer have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1833), suspension sleeve (L2397), ankle foot orthosis (L1971) and heel stabilizer (L3170) provided September 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the four gingival irrigations, drugs or medicaments dispensed in the office for home use, and periodontal scalings and root planings of all four quadrants on November 3, 2020.
You asked the Plan to pay for the gingival irrigations, drugs or medicaments, and scalings and planings. You say that you feel you should not be held responsible for this bill. The Plan denied your request. The Plan says the gingival irrigations and drugs or medicaments are not covered services. The Plan also says that you have exceeded the Plan's frequency limit for the scalings and planings.
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, gingival irrigation and drugs or medicaments dispensed in the office for home use are not among those covered under this benefit. The contract says that you are limited to no more than one periodontal scaling and root planing per quadrant in any 24-month period. The record shows that you received periodontal scalings and root planings for two quadrants on October 14, 2019, and periodontal scalings and root planings on November 4, 2019 of the remaining two quadrants, and your periodontal scaling and root planing benefit for each quadrant have been exhausted. Therefore, we decided that the Plan does not have to pay for the four gingival irrigations, drugs or medicaments dispensed in the office for home use, and periodontal scalings and root planings of all four quadrants on November 3, 2020.