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

We decided that the Plan does not have to pay for the lab services provided on December 23, 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. There
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayments for the needle injection and physical therapy provided on May 20, 2020.
You asked the Plan to reduce the copayments for the needle injection and the physical therapy. You say that you should only be charged one copayment for one visit. 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 $35 copayment per visit to a specialist and a $35 copayment per Medicare-covered visit of physical therapy, occupational therapy, and speech language therapy services. You have been asked to pay a $35 copayment for the needle injection and a $35 copayment for the physical therapy. The needle injection falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows the needle injection is considered a specialist service. The physical therapy falls within the "Outpatient rehabilitation services" benefit category. The record shows two separate services were performed during one 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 reduce the copayments for the needle injection and physical therapy provided on May 20, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on January 4, 2021.
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 January 4, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for manual therapy provided on August 27, 2020.
You asked the Plan to pay for the manual therapy. You say that you received a technique called myofascial release, which helps you be pain free and off pain prescriptions. The Plan denied your request. The Plan says we only cover chiropractic services for manual manipulation of the spine to correct subluxation. All other services with a chiropractor are not covered.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. We looked at the file, the Plan's rules and Medicare rules. The file shows that the Plan only covers chiropractic services for manual manipulation of the spine to correct subluxation. The only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. Therefore, we decided that the Plan does not have to pay for manual therapy provided on August 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the ankle foot orthosis and heel stabilizer provided on June 18, 2020.

You asked the Plan to pay for the ankle foot orthosis, plastic or other material with ankle joint, prefabricated, includes fitting and adjustment (L1971RT), Foot, plastic, silicone or equal, heel stabilizer, prefabricated, off-the-shelf, each (L3170RT). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the invoice and proof of delivery are dated prior to the date of service.

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. The claim date and date of delivery show significant variation. 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 ankle foot orthosis and heel stabilizer provided on June 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the unspecified periodontal procedure, by report (D4999), gingival irrigation - per quadrant (D4921), and periodontal scaling and root planing - four or more teeth per quadrant (D4341) provided November 25, 2020.

You asked the Plan to pay for the unspecified periodontal procedure, gingival irrigation and periodontal scaling and root planing. You say that you were told you could get reimbursement up to $1,750. The Plan denied your request. The Plan says you have been reimbursed the full $1,275.00 allowed under your 2020 plan benefits and therefore no further reimbursement is due.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the unspecified periodontal procedure, gingival irrigation and periodontal scaling and root planing when the services are medically necessary and reasonable. 

We looked at the file and Medicare rules. The Plan provided documentation showing you have been covered for dental services up to the $1,275 dental maximum for the year 2020. Therefore, we decided that the Plan does not have to pay for the unspecified periodontal procedure, by report (D4999), gingival irrigation - per quadrant (D4921), and periodontal scaling and root planing - four or more teeth per quadrant (D4341) provided November 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for wound care services and facility charges (11042, 11043) provided from December 1, 2020 to January 11, 2021.

You asked the Plan to waive the cost-sharing for wound care services and facility charges. You say that these charges are too high for the services provided. The Plan denied your request. The Plan says these services processed 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 15% coinsurance for outpatient surgery, including services provided at hospital outpatient facilities and a $30 copayment for medical care or surgery service provided by a specialist.

You have been asked to pay a $30 copayment for each wound care service and pay a 15% coinsurance for facility charges. 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-sharing for wound care services and facility charges (11042, 11043) provided from December 1, 2020 to January 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the frames (V2020) and the progressive lenses (V2781 x2) received July 22, 2020 from the out-of-network provider.

You asked the Plan to pay for the frames and lenses. You say that the out-of-network provider is the only provider with frames that fit you. The Plan denied your request. The Plan says there is no coverage for routine vision care received out-of-network.

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. The Plan covers these services when purchased from a network provider.

We looked at the file and the Plan's rules. Although the Plan provides a $200 benefit allowance for routine vision care services, this benefit is not available for services received outside of the Plan network. The frames and lenses purchased in this case were purchased out-of-network. Based on this information, we decided that the Plan's rules for coverage of the frames and lenses have not been met. Therefore, we decided that the Plan does not have to pay for the frames (V2020) and the progressive lenses (V2781 x2) received July 22, 2020 from the out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ear wax removal provided on January 19, 2021.

You asked the Plan to waive the copayment for the ear wax removal. You say that you had the same appointment last year and it was $0. 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 $25 copayment for an in-network specialty care physician.

You have been asked to pay a $25 copayment for the ear wax removal. The ear wax removal falls within the "Physician/Practitioner services, including doctor's office visits" 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 ear wax removal provided on January 19, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services rendered from November 30,
2019, to December 9, 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 records do not support the billed DRG and diagnosis code.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the
reported principal and secondary diagnosis codes.

In this case, you billed the inpatient services provided with DRG 481 and diagnosis code E78.1 (Hypoosmolality
and hyponatremia). 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 these services.
Our reviewer says that the records do not support the billed DRG and diagnosis code. Our physician reviewer
found the records showed that the enrollee had borderline low sodium or normal sodium levels and did not
have any other signs or symptoms suggestive of clinically significant hyponatremia or hypo-osmolality to list
this as a main diagnosis for admission. Therefore, the code, E78.1 and therefore, the DRG of 481 are both not
supported in the provided records.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay
for the inpatient hospital services rendered from November 30, 2019, to December 9, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited oral evaluation (D0140), periodontal maintenance (D4910), and an excision of benign lesion (D7410) provided on July 21, 2020.

You asked the Plan to pay for a limited oral evaluation, periodontal maintenance, and an excision of benign lesion. You say that the services were medically necessary. The Plan denied your request. The Plan says the services at issue are not covered benefits.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a limited oral evaluation, periodontal maintenance, and an excision of benign lesion when the services are medically necessary and reasonable. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for a limited oral evaluation, periodontal maintenance, and an excision of benign lesion. Our reviewer says that there was no medical necessity for the excision of the benign lesion (D7410). The lesion was benign. The area of treatment was the cheek and not the supporting structures of the teeth. As the lesion was not cancerous and was not painful or likely to change further, there was no medical necessity for removal.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a limited oral evaluation, periodontal maintenance, and an excision of benign lesion have not been met. Specifically, the services at issue were determined to be not medically necessary. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140), periodontal maintenance (D4910), and an excision of benign lesion (D7410) provided on July 21, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on October 28, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component (TC) indicator of 8 identifies professional component of clinical laboratory codes for which separate payment may be made only if the physician interprets an abnormal smear for hospital inpatient. 

We looked at the file and Medicare rules. The file shows that procedure code 85060 was not performed for a hospital inpatient. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on October 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the specialist office visits provided from September 30, 2020, to March 2, 2021.

You asked the Plan to waive the copayments for the specialist office visits. You say that you should be reimbursed the copayment amounts you paid at the time of service. 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 $50 copayment for provider and professional services at an in-network specialist's office.

You have been asked to pay a $50 copayment for each of the specialist office visits. The specialist office visits fall within the "Physician/Practitioner services, including doctor's office visits" 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 copayments for the specialist office visits provided from September 30, 2020, to March 2, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy re-evaluation (97161) therapeutic activities (97530) therapeutic exercises (97110) manual therapy techniques (97140) provided October 7, 2020 to November 20, 2020.

You asked the Plan to waive the copayment for the PT services. You say that it was discovered the PT provider submitted claims using incorrect treatment codes. Use of correct codes will now provide for full payment by the plan with no copays to you. Please reprocess using correct codes. The Plan denied your request. The Plan says the claims were processed and the correct copayments were applied per the Evidence of Coverage.

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 $35 copay Medicare covered physical therapy.

You have been asked to pay $385 for the PT services. The PT services falls within the Outpatient rehabilitation 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 copayment for physical therapy re-evaluation (97161) therapeutic activities (97530) therapeutic exercises (97110) manual therapy techniques (97140) provided October 7, 2020 to November 20, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a spinal distraction device.

You asked the Plan to pre-approve the insertion of a spinal distraction device. You say that the enrollee has suffered with back pain that has greatly impacted his life. You say that this conservative procedure is a safer alternative to a spinal fusion. The Plan denied your request. The Plan says the current medical literature does not support the use of the requested device for long term relief of back and leg pain.

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 the insertion of a spinal distraction device. Our reviewer says that the insertion of a spinal distraction device is not considered medically reasonable and necessary in this case. Our physician reviewer found 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 this enrollee's medical condition. 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 including the planned level of implantation L3-4 and L4-5. FDA contraindications include spinal instability, scoliosis, obesity, and osteoporosis, and which have not been adequately addressed in the medical records. There is no discussion of spinal instability on flexion/extension films. There is imaging evidence of mild dextroscoliosis of the lower lumbar spine, with no updated documentation of the Cobb angle. There is no discussion indicating that a DEXA scan has demonstrated the lack of significant osteoporosis in this enrollee. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for Superion interspinous spacer (Vertiflex device) at L3-4 and L4-5 levels 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 the insertion of a spinal distraction device have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of a spinal distraction device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve for an inpatient hospital admission.

You asked the Plan to pre-approve for acute inpatient hospital care. You say that the records provided support the need for the services in dispute. The Plan denied your request. The Plan says there is no documentation provided to support the expectation that the enrollee will require a greater than 2 midnight stay.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 

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 for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee presented to the hospital for an elective partial knee arthroplasty procedure. His medical history and recent notes did not reveal evidence to suggest he would need a longer than expected recovery or a complication risk during the procedure to justify inpatient admission associated with this surgery, which is elective. The records do not suggest the enrollee would require hospitalization that would likely cross 2 midnights.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve for an inpatient hospital admission.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an unspecified oral surgery - surgical extractions (D7999).

You asked the Plan to pre-approve an unspecified oral surgery - surgical extractions. You say that the services at issue are necessary and you want the Plan to pay for them. The Plan denied your request. The Plan says the services at issue are not covered benefits.

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 pre-approve an unspecified oral surgery - surgical extractions (D7999).