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

We decided that the Plan does not have to pay for the eye refraction services provided on November 24, 2020.
You asked the Plan to pay for the eye refraction. You say that you had a second checkup after surgery. The Plan denied your request. The Plan says eye refractions are only covered when performed as routine.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file and the Plan's rules. The records do not show that the eye refraction was performed as part of a routine eye exam. Based on this information, we decided that the Plan's rules for coverage of the eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for the eye refraction services provided on November 24, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a Superion interspinous stabilization device (22869, 22870).
You asked the Plan to pre-approve this service. You say that this service is medically necessary for the treatment of lumbar spinal stenosis. The Plan denied your request. The Plan says this service 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 this service. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found that current evidence based medical guideline and peer reviewed literature do not fully support the spinal decompression device procedure over the 'gold standard' of lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for the enrollee's medical condition. The Food and Drug Administration (FDA) indications include implantation of the Superion device at one or two adjacent lumbar levels in patients with moderate spinal stenosis in whom operative treatment is indicated at no more than two levels, from L1 to L5. This enrollee has multiple degrees of spinal stenosis, many not at FDA indicated levels of "moderate" spinal stenosis. FDA contraindications include spinal instability, scoliosis, obesity, and osteoporosis, and have not been adequately addressed in the medical records. There is imaging evidence of spondylolisthesis with no discussion of spinal instability on flexion/extension films. There is imaging evidence of a levoconvex curve of the lumbar spine with no documentation of the Cobb angle. Additionally, there is no discussion indicating that a dual-energy x-ray absorptiometry (DEXA) scan has demonstrated the lack of significant osteoporosis in this patient. Therefore, the requested service is not medically reasonable or necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of a Superion interspinous stabilization device (22869, 22870).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for Fundus photography with interpretation and report (92250) provided December 15, 2020.
You asked the Plan to pay for the diagnostic services. You say that your primary physician recommended you get examined by an ophthalmologist because you are a diabetic and have not had an eye exam for over a year. You selected this provider for the plan's list of eye centers. The Plan denied your request. The Plan says this service is bundled to another service billed on the same day by the same physician, or a physician of the same specialty in the same group.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code the diagnostic services has a bundled relationship with code 92134 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for Fundus photography with interpretation and report (92250) provided December 15, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a cardiovascular panel (81286, 81404, 81407, 81408, 81479) provided on June 4, 2020.
You asked the Plan to pay for a cardiovascular panel. You say that this should be covered. The Plan denied your request. The Plan says this was not ordered by a treating practitioner.
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular (CV) risk assessment panels, except the basic lipid panel, for symptomatic (with signs and symptoms) patients with suspected or documented CV disease because panel testing is not specific to a given patient's lipid abnormality or disease. We looked at the file and Medicare rules. The services at issue are a CV risk assessment panel and are not covered. Based on this information, we decided that Medicare rules for coverage of a cardiovascular panel have not been met. Therefore, we decided that the Plan does not have to pay for a cardiovascular panel (81286, 81404, 81407, 81408, 81479) provided on June 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the automatic blood pressure monitor (A4670) provided on September 30, 2020.
You asked the Plan to pay for the automatic blood pressure monitor. You say that you would like reconsideration because you were not educated on the process of using your over the counter benefits. The Plan denied your request. The Plan says you purchased this equipment from a vendor who is not a Medicare participating provider.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the automatic blood pressure monitor (A4670) provided on September 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series of intraoral x-rays.

You asked the Plan to pay for the complete series of intraoral x-rays. You say that you do not feel you should be responsible for this bill. The Plan denied your request. The Plan says benefits for this service have been satisfied and the frequency limitation has been exceeded. The Plan also says that no benefits were verified prior to the services being rendered.

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, full mouth or panoramic x-rays is limited to one procedure every three years. The record shows that you received a complete series of intraoral x-rays on November 18, 2019 and your full mouth or panoramic x-rays benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the complete series of intraoral x-rays.

Your complaint about possibly being given misleading information 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 needle electromyography (95861 and 95868), somatosensory testing (95927 and 95938) and central motor evoked potential study (95939) provided on July 9, 2020.
You asked the Plan to pay for the neuromonitoring services. You say that you would like reconsideration as you do not have an arrangement with the facility receive reimbursement for your services. The Plan denied your request. The Plan says the member was inpatient on the billed date of service and these services are not separately payable in a facility setting.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find that CPT codes 95939, 95938, 95861, 95868 and 95927 are not supported in the record. Specifically, the record indicates that the member was inpatient on the billed date of service. Place of service code 15 is not appropriate in this case. Additionally, payment for this service is the responsibility of the facility to any vendor. Based on this information, we decided that Medicare rules for coverage of the neuromonitoring services have not been met. Therefore, we decided that the Plan does not have to pay for needle electromyography (95861 and 95868), somatosensory testing (95927 and 95938) and central motor evoked potential study (95939) provided on July 9, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee from July 13, 2020, to July 19, 2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says Current Procedural Terminology (CPT) code G0156 (140 unit) remains not supported. The documentation submitted did not include time spent with the enrollee. The billed service cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate documentation. In this case, the records provided do not support the services billed. Medicare coverage criteria are not met. Therefore, we decided that the Plan does not have to pay for home health services provided to the enrollee from July 13, 2020, to July 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on December 10, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says prior authorization was not obtained by the provider or facility. The provider should have verified the member's eligibility, health benefits and obtained authorization prior to the member s visit before providing services to the member as outlined on the member's ID card.
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 December 10, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the ambulance transportation services provided on December 3, 2020.
You asked the Plan to waive the copay for the services provided. You say that your husband could have driven you to the hospital. The Plan denied your request. The Plan says the claim paid 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 $250 copay for ambulance services. You have been asked to pay a $250 copay for the services provided. The services fall within the ambulance services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copay for the ambulance transportation services provided on December 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary visit provided on September 23, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the domiciliary visit. You say that the services were medically necessary. 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 had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for a domiciliary visit provided on September 23, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the CT scan provided on July 13, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the CT scan. You say that the services were medically necessary. 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 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 CT scan provided on July 13, 2020 by an out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services (G0156, S9122).

You asked the Plan to pay for the home health services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says there is insufficient documentation to corroborate the services and confirm Medicare coverage has been met.

The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program.

Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Additionally, the documentation submitted does not include any medical records to verify the billed services and confirm that Medicare coverage criteria have been met. Therefore, we decided that the Plan does not have to pay for the home health services (G0156, S9122).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the homemaker services provided from June 1, 2020, to July 1, 2020.
You asked the Plan to pay for the homemaker services. You say that You say that the enrollee fell and injured your right shoulder. You say that this was a result of late stage Parkinson's Disease. You say that the assisted living facility informed you that you are required to hire a certified health aid for the enrollee. You also say that you were advised by 2 insurance agents that the services would be covered. The Plan denied your request. The Plan says homemaker services are not covered.
The Plan must follow Medicare rules. Custodial care is not covered. We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the homemaker services have not been met. Therefore, we decided that the Plan does not have to pay for the homemaker services provided from June 1, 2020, to July 1, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve Septoplasty.
You asked the Plan to pre-approve Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft (30520). You say that imaging revealed a sphenoid sinus mass. The Plan denied your request. The Plan says that the enrollee does not present with symptoms of nasal congestion or difficulty breathing.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 pre-approve Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft (30520). Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the patient will be undergoing endoscopic sinus surgery in order to address a concerning mass in the sphenoid sinus. In order to access the sinus, a septoplasty may need to be performed. A cartilaginous and/or bony deviation of the septum can make it difficult or impossible to access the sphenoid os. In addition, if the sphenoid has to be opened widely, then the posterior septum needs to be removed in order to access and drill the intersinus septum. This patient likely needs the entire sphenoid sinus to be opened in order to remove the lesion without injuring the carotid artery. In this case where wide access is needed, a septoplasty will likely be performed in order to gain this access. The septoplasty is not being performed for a routine nasal obstruction or congestion, but rather in order to perform the critical portion of the procedure which is sphenoidotomy with excision of a potential neoplasm. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft (30520) have been met. Therefore, we decided that the Plan has to pre-approve Septoplasty.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a positioning cushion.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
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-approve a positioning cushion.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140), the collection and
application of autologous blood concentrate product (D7921) the sinus augmentation with bone or bone
substitutes (D7951), and the non-intravenous conscious sedation (D9248) provided from August 10, 2020, to
September 4, 2020.
You asked the Plan to pay for the dental services. You say that you feel that the back tooth you had removed on
the date of service should be covered since it was not easy to find during the pandemic. You say that you
received an estimate of $458 and another for removal tooth removal, sinus augmentation, and autologous bone
growth at $2,885. You say that you went with the second estimate and are waiting for it to heal so you can get
an implant. You also say that you would like the removal of your infected tooth to be paid for. The Plan denied
your request. The Plan says 1 limited oral evaluation is covered per plan year. The Plan says that the frequency
limit for this service has been exceeded. The Plan also says that the collection and application of autologous
blood concentrate product, sinus augmentation, and non-intravenous conscious sedation are not listed as
covered services.
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 and limited oral evaluation is listed as a
covered service, the frequency limit has been exceeded. The record shows that the Plan paid for this service
that you received on July 28, 2020. Additionally, the collection and application of autologous blood
concentrate product, sinus augmentation, and non-intravenous conscious sedation are not among those covered
under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation
(D0140), the collection and application of autologous blood concentrate product (D7921) the sinus
augmentation with bone or bone substitutes (D7951), and the non-intravenous conscious sedation (D9248)
provided from August 10, 2020, to September 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and panoramic x-ray (D0330) provided on November 9, 2020.
You asked the Plan to pay for the oral evaluation and x-ray. You say that it is necessary for you to have these services due to a medical condition and medications you take. The Plan denied your request. The Plan says they already covered a comprehensive oral exam and a full mouth x-ray in June of 2020, which was only five months before the date of service in question. Comprehensive evaluations or exams will only be covered once per 36-month period. Panoramic or full mouth x-rays will also only be covered once every 36 months. The benefit for these services was already used and exhausted on June 26, 2020.
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 covered under this benefit more than once in a 36-month period. The Plan provided documentation that they previously paid for these services less than 36 months ago. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and panoramic x-ray (D0330) provided on November 9, 2020.