Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services (A0425, A0428) provided on November 5, 2019 and an office visit with a podiatrist (99203) provided on November 19, 2019.
You asked the Plan to waive the copayment for ambulance services and an office visit with a podiatrist. You say that these services were medically necessary so you shouldn't have to pay for them. The Plan denied your request. The Plan says these services processed with the correct copayments per your contract with the Plan.
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 $260 copayment for each Medicare-covered one-way ambulance trip and a $45 copayment for specialist services. You have been asked to pay $258.63 for ambulance services. You have been asked to pay less than your listed copayment because the allowed amount for these services totaled less than the copayment specified in the EOC. You have also been asked to pay $45 for an office visit with a podiatrist. A podiatrist is considered a specialist. 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 ambulance services (A0425, A0428) provided on November 5, 2019 and an office visit with a podiatrist (99203) provided on November 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone growth stimulator (E0747).You asked the Plan to pre-approve bone growth stimulator. You say that the records should support the necessity of the service in dispute.The Plan denied your request. The Plan says this service is not considered medically necessary.The Plan must follow Medicare rules. The rules say that an electrical bone stimulator is covered for nonunion of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial radiographs have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment with the electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs separated by a minimum of 90 days. 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 bone growth stimulator. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the guidelines require that serial radiographs have confirmed that fracture healing had ceased for 3 or more months prior to starting treatment with the electrical osteogenic stimulator. There are no medical risk factors noted for this enrollee. Given the inconsistencies between the podiatrist and radiologist report of findings, Medicare criteria have not been met at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of bone growth stimulator have not been met.Therefore, we decided that the Plan does not have to pre-approve bone growth stimulator (E0747).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve a referral to neurosurgery.
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 that the referral is not medically necessary.
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 these services. Our reviewer says that the referral is medically necessary. Our physician reviewer found the enrollee has low back pain radiating to the right lower extremity with worsening weakness. He has been evaluated by a neurologist who has requested neurosurgical consultation. Given the enrollee's surgical history, worsening symptoms and neurologic findings consistent with nerve root compression, and completion of a neurology consultation, this request for neurosurgical consultation is reasonably indicated without physiatrist evaluation. Therefore, this request for referral to a neurosurgeon is reasonable and medically 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 these services have been met. Therefore, we decided that the Plan has to pre-approve a referral to neurosurgery.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental discount card, prophylaxis, periodic oral evaluation, and complete series of intraoral x-rays provided on September 13, 2019 and October 3, 2019.
You asked the Plan to pay for the dental discount card, prophylaxis, periodic oral evaluation, and complete series of intraoral x-rays. You say that you expect to be reimbursed for these services because you are paying privately for the additional discount. The Plan denied your request. The Plan says the claim has been processed correctly according to your plan of benefits, and no additional reimbursement is due to you. The Plan also says that they made payment according to the Medicare allowable rates.
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, dental discount card is not a covered benefit. The contract clearly states that you are responsible for a 50% coinsurance for non-Medicare covered preventive and comprehensive dental services when they are received by an out-of-network provider. The record shows that you were billed correctly at 50% coinsurance for these services. Therefore, we decided that the Plan does not have to pay for the dental discount card, prophylaxis, periodic oral evaluation, and complete series of intraoral x-rays provided on September 13, 2019 and October 3, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urgent care visit provided on January 10, 2020.You asked the Plan to waive the copayment for the urgent care visit. You say that you were told the urgent care visit was in-network and were told nothing about a copayment. The Plan denied your request. The Plan says you have been charged 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 $65 copayment for each in-and-out-of-network Medicare-covered urgent care facility visit. You have been asked to pay a $65 copayment for the urgent care visit. The urgent care visit falls within the "Urgently needed 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 the urgent care visit provided on January 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids purchased on September 10, 2019.You asked the Plan to pay for the hearing aids. The Plan denied your request. The Plan says that there is no coverage if hearing aids or related services are received from a provider not part of the plan's hearing aid vendor's network.Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only ordered through in network providers. We looked at the file and the Plan's rules. The file indicates the hearings aids were not ordered through in network providers. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met.Therefore, we decided that the Plan does not have to pay for the hearing aids purchased on September 10, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on October 7, 2019. You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.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 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 physician's services provided on October 7, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a shoulder-hand-wrist orthosis (L3960) provided to the enrollee on November 22, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The rules say for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. When conducting a review of a covered DME item, ordered by a physician, the contractor shall ensure that the physician saw the beneficiary and conducted a face-to-face assessment. Therefore, we decided that the Plan does not have to pay for a shoulder-hand-wrist orthosis (L3960) provided to the enrollee on November 22, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the open treatment of complicated fracture(s) coded 21365, open treatment of orbital floor blowout fracture coded 21390, and the open treatment of nasoethmoid fracture services coded 21338 provided on September 25, 2019.
You asked the Plan to pay for the open treatment of complicated fracture(s), open treatment of orbital floor blowout fracture and the open treatment of nasoethmoid 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. We find that CPT codes 21365, 21390, and 21338 are not supported in the medical record. Specifically, these services were billed with modifier -62 (co-surgeon). However, the modifier is not supported in the brief operative report. Based on this information, we decided that Medicare rules for coverage of the open treatment of complicated fracture(s), open treatment of orbital floor blowout fracture and the open treatment of nasoethmoid fracture services have not been met. Therefore, we decided that the Plan does not have to pay for the open treatment of complicated fracture(s) coded 21365, open treatment of orbital floor blowout fracture coded 21390, and the open treatment of nasoethmoid fracture services coded 21338 provided on September 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the CPAP supplies provided on December 2, 2019.You asked the Plan to pay for the CPAP supplies. The Plan denied your request. The Plan says that the provider is not eligible to participate in Medicare.The Plan must follow Medicare rules. The rules state that Medicare payment cannot be made to a supplier who is not enrolled in theMedicare Program.The purchase was not made with a supplier who is enrolled in the Medicare program.Therefore, we decided that the Plan does not have to pay for the CPAP supplies provided on December 2, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services rendered on October 19, 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 procedure code 95999 is not supported.
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 95999 is unlisted neurological or neuromuscular diagnostic procedure. We find that CPT code 95999 is not supported in the medical record. Specifically, the records show that Train of Four testing was performed and there is a more appropriate code for these services. 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 testing services rendered on October 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on February 26, 2020.
You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.
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 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 a domiciliary, rest home visit provided on February 26, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Testosterone Cypionate.
You asked the Plan to pre-approve Testosterone Cypionate. You say that the enrollee needs this drug. The Plan denied your request. The Plan says this drug is not a Part B drug and therefore not covered by the Plan.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Testosterone Cypionate.
Benefits for Testosterone Cypionate may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomography (CT) scan services.You asked the Plan to pre-approve the CT scan. You say that the enrollee had no improvement with cough and shortness of breath after medications were prescribed and the recent x-ray results. You say that the enrollee should complete a CT scan in order to properly treating ongoing issues and to ensure resolution of pneumonia and infiltrates.The Plan denied your request. The Plan says they do not see results of a chest x-ray showing complication of pneumonia, or a possible lung mass associated with an infiltrate.The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the CT scan. Our reviewer says that the requested CT scan is not medically reasonable and necessary. Our physician reviewer found the enrollee is experiencing recurrent upper respiratory symptoms. Two recent CXRs have shown no acute disease.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 CT scan have not been met.Therefore, we decided that the Plan does not have to pre-approve computed tomography (CT) scan services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional mileage You asked the Plan to pre-approve the additional mileage. You say that this is medically necessary.The Plan denied your request. The Plan says the benefit only allows for 50 miles each one-way.Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers routine transportation when each trip is under 50 miles one-way. We looked at your request, the records in the case file, and the rules. The requested trip is two miles over the benefit limit. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met.Therefore, we decided that the Plan does not have to pre-approve additional mileage
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a neck spine x-ray (72052), spine x-ray (72110), thoracic spine x-ray (72072), and ankle x-ray (73610-26-LT) provided on January 9, 2020 by the appealing provider.
You asked the Plan to pay for the neck spine x-ray, spine x-ray, thoracic spine x-ray, and ankle x-ray. You say that the services were provided and payment should be rendered. The Plan denied your request. The Plan says the billed codes are duplicate claim lines. Based on Medicare billing criteria, duplicate claims are not eligible for payment.
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 72052, 72110, 72072, 73610-26-LT are not supported in the medical record. Specifically, each claim was billed as 72052, 72110, 72072, 73610-26-LT which is duplicate billing. Codes 72052, 72110, 72072, 73610-26-LT were already paid by the plan. Based on this information, we decided that Medicare rules for coverage of the neck spine x-ray, spine x-ray, thoracic spine x-ray, and ankle x-ray have not been met. Therefore, we decided that the Plan does not have to pay for a neck spine x-ray (72052), spine x-ray (72110), thoracic spine x-ray (72072), and ankle x-ray (73610-26-LT) provided on January 9, 2020 by the appealing provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthosis (L1851) and suspension sleeve (L2397) provided November 12, 2019.
You asked the Plan to pay for the orthoses. You say that the records provided should support the necessity of the service in dispute. The Plan denied your request. The Plan says the records provided do not support the service billed.
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 physician order for the items at issue in this appeal. The record does not contain a valid physician order for the supplies provided in this case and the NPI number submitted on the RX/Medical Necessity form does not belong to the ordering provider. Therefore, we decided that the Plan does not have to pay for knee orthosis (L1851) and suspension sleeve (L2397) provided November 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for lumbar-sacral orthosis (L0650) provided December 6, 2019.
You asked the Plan to pay for the orthosis. You say that the records provided should support the necessity of the service in dispute. The Plan denied your request. The Plan says there is no evidence of an established relationship between the enrollee and the ordering physician, there was no claims submitted for an evaluation and management service and there is no evidence of a prior telehealth service with the ordering physician as required per CMS guidelines.
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/services ordered following the non-covered visit are likewise non-covered. Therefore, we decided that the Plan does not have to pay for lumbar-sacral orthosis (L0650) provided December 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the vertebral corpectomy services coded 63091 provided on July 1, 2019.
You asked the Plan to pay for the vertebral corpectomy 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 63091 is vertebral corpectomy (vertebral body resection), partial or complete, transperitoneal or retroperitoneal approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic, lumbar, or sacral; each additional segment (List separately in addition to code for primary procedure). We find that CPT code 63091 is not supported in the medical record. Specifically, the operative report did not include documentation of a partial or complete vertebral corpectomy (vertebral body resection), using a transperitoneal or retroperitoneal approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic, lumbar, or sacral; for each additional segment. Based on this information, we decided that Medicare rules for coverage of the vertebral corpectomy services have not been met. Therefore, we decided that the Plan does not have to pay for the vertebral corpectomy services coded 63091 provided on July 1, 2019.