Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you additionally for the rollator and seat attachment purchased on June 24, 2020.
You asked the Plan to reimburse you additionally for the rollator and seat attachment. You say that you do not understand why the reimbursed amount is so low. The Plan denied your request. The Plan says you were paid the Medicare allowable rate minus your copayment.
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 Durable Medical Equipment. You have been asked to pay a $10 copayment for the rollator. The rollator falls within the Durable Medical Equipment 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. The fee schedule is a complete listing of fees used by Medicare to pay suppliers. The Plan has reimbursed you the Medicare allowable rate, $64.52 for the rollator, and $17.57 for the seat attachment. Therefore, we decided that the Plan does not have to reimburse you additionally for the rollator and seat attachment purchased on June 24, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a PET scan with CT for attenuation for the enrollee.
You asked the Plan to pre-approve the scan. You say that this is medically necessary for evaluation of brain abnormalities. The Plan denied your request. The Plan says there are no notes showing why the doctor wants this test.
The Plan must follow Medicare rules. Medicare rules say that PET/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 scan. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found the record indicates that the enrollee has a suspected diagnosis of Lewy Body dementia with Parkinson's disease. The record does not indicate that the enrollee has had neurocognitive testing documenting a decline over a six month period of time. Laboratory evaluation has not been performed. The elements of the coverage rule 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 the scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a PET scan with CT for attenuation for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient skilled nursing services provided on October 1, 2020, to November 19, 2020 by an OON provider.

You asked the Plan to pay for the inpatient skilled nursing services. You say that these services were provided with no adequate time frame to obtain an authorization. The Plan denied your request. The Plan says prior authorization was not 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 the inpatient skilled nursing services provided on October 1, 2020, to November 19, 2020 by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation, Kyphoplasty
(22513).

You asked the Plan to pre-approve Kyphoplasty. You say that the service is medically necessary. The Plan
denied your request. The Plan says the service is not medically necessary.

The Plan follows Medicare rules. Medicare rules say that kyphoplasty is not appropriate when the vertebral
body fracture is associated with widened pedicles or retropulsion of bone as in a burst fracture.

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 Kyphoplasty. Our reviewer says that
the service is not medically necessary. Our physician reviewer found the records show that this is a burst
fracture, and not a compression fracture. Kyphoplasty is contraindicated in burst fracture where there is bone in
the spinal canal. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Kyphoplasty have not been met. Specifically, the enrollee has a burst fracture. This means the service is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve percutaneous vertebral augmentation, Kyphoplasty (22513).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound (76881) provided on
November 6, 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). Your contract with the Plan clearly says that you must pay a $60
copayment for Medicare-covered x-rays and ultrasounds.

You have been asked to pay a $60 copayment for the ultrasound provided. 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 ultrasound (76881) provided on November 6, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital services rendered on January 7, 2021.

You asked the Plan to waive the copayment for these services. You say that you disagree with the charges. The Plan denied your request. The Plan says the copayment was 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 $360 copayment per day for days 1-5 for each Medicare-covered hospital stay.

Review of the file shows that you received inpatient hospital services on January 7, 2021. You have been asked to pay a $360 copayment for these services. These services fall within the Medicare-covered hospital stay 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 inpatient hospital services rendered on January 7, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency room visit provided by a participating provider on January 22, 2021.

You asked the Plan to waive the copayment for emergency room visit. You say that the care that you received does not warrant this copayment. The Plan denied your request. The Plan says the correct copayment has been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 copayment for emergency care. 

You have been asked to pay a $90 copayment for emergency room visit. Since an emergency room visit took place, the correct copayment has been applied. An emergency room visit falls within the emergency care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for emergency room visit provided by a participating provider on January 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for orthoses (L1833, L2397) provided to the enrollee on July 31, 2020.

You asked the Plan to pay for the orthoses. You say that this is medically necessary. The Plan denied your request. The Plan says the provider is known for utilizing a telephonic consult to obtain the clinical information for durable medical equipment.

The Plan must follow Medicare rules. The Plan must follow Medicare rules. Medicare rules say that durable medical equipment generally must be ordered by a physician who has furnished a consultation or treats an enrollee for a specific medical problem. 

The file does not contain documentation of an established relationship between the enrollee and the ordering provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of the orthoses have not been met. Based on this information, we decided that Medicare rules for coverage of the orthoses have not been met. Therefore, we decided that the Plan does not have to pay for orthoses (L1833, L2397) provided to the enrollee on July 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on October 16, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that for conditions that have both an underlying etiology and multiple body system manifestations due to the underlying etiology, the ICD10-CM has a coding convention that requires the underlying condition be sequenced first, if applicable, followed by the manifestation. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the requested service have not been met. Specifically, the record shows that the claim was billed with primary diagnosis code, I25.82. This code has a code first note, which means it is a manifestation code and must be sequenced after an etiology code. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services provided on October 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee brace (L1833, L2397) provided on March 29, 2021.

You asked the Plan to pay for a knee brace. You say that this is supported in the records. The Plan denied your request. The Plan says there is not a valid proof of delivery.

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 itemized invoice does not include the carrier's tracking number, therefore the specific items at issue cannot be verified as delivered. 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 a knee brace (L1833, L2397) provided on March 29, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to waive the coinsurance for the routine venipuncture (36415) and the laboratory
service provided on March 25, 2021.

You asked the Plan to waive the coinsurance for these services. You say that you are requesting a
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that the
coinsurance 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. Your
contract with the Plan says that enrollees must pay a $0 copayment for lab services provided at an outpatient
hospital.

The Plan says you must pay a $2.22 coinsurance for the laboratory services provided. Based on the Plan
contract, however, you cannot be asked to pay more than a $0 copayment/coinsurance for laboratory services
provided. Therefore, we decided that the Plan has to waive the coinsurance for the routine venipuncture
(36415) and the laboratory service (85025) provided on March 25, 2021.

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 pre-approve a retainer crown - porcelain/ceramic (D6740), pontic - porcelain/ceramic (D6245), and a crown - porcelain/ceramic (D2740) for tooth 20.

You asked the Plan to pre-approve a retainer crown, pontic and crown. You say that you broke you tooth, and the dental services are medically necessary. The Plan denied your request. The Plan says the retainer crown and pontic are not covered under your dental benefits. You have met frequency limits for a crown for tooth 20.

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 crown once per tooth every 60 months.

We looked at the file and Medicare rules. The Plan provided documentation showing that a crown was previously covered for tooth 20 on December 28, 2019. Based on this information, we determined that the Plan's frequency limit for a crown for tooth 20 has been met. Though the Plan over dental benefits in excess of Medicare coverage, the retainer crown and pontic are not among those covered services. Therefore, we decided that the Plan does not have to pre-approve a retainer crown - porcelain/ceramic (D6740), pontic - porcelain/ceramic (D6245), and a crown - porcelain/ceramic (D2740) for tooth 20.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis provided on March 24, 2021.

You asked the Plan to pay for the prophylaxis. You say that The Plan contract says an oral prophylaxis is covered every six months. The Plan denied your request. The Plan says coverage for this procedure is limited to once in a six-month period.

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, you also have a maximum benefit of one oral prophylaxis every six months. The Plan paid for a prophylaxis provided on February 25, 2021, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the prophylaxis provided on March 24, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provided on
December 22, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says out-of-network
services are not covered.

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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided by an out-of-network provided on December 22, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the laboratory work provided on February
23, 2021.

You asked the Plan to waive the deductible for the laboratory work. You say that laboratory costs should be
excluded from the deductible. 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. Your
contract with the Plan says that there is a $300 deductible that applies towards laboratory work.

The laboratory work you asked the Plan to waive the deductible for falls within the "Outpatient diagnostic tests
and therapeutic services and supplies" benefit category. The Plan has followed Medicare rules by clearly
disclosing in the contract that there is a $300 deductible that applies towards laboratory work.

This cost sharing is a contractual obligation that had not been met at the time the laboratory work was received
on February 23, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the
laboratory work provided on February 23, 2021.

Your complaint about the benefit design 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (71275) provided on January 16, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services are 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 71275 is "Computed tomographic angiography, chest (noncoronary), with contrast material(s), including noncontrast images, if performed, and image postprocessing". 

We find that CPT code 71275 is not supported in the medical record. Specifically, the records support the only one unit of CPT code 71725 was provided on the date of service in question, which was previously processed and paid by the Plan. An additional unit of this code is not supported. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services (71275) provided on January 16, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on November 9, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.

The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.

We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on November 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited oral evaluation (D0140), and an intraoral periapical radiographic image (D0230) provided on April 7, 2021.

You asked the Plan to pay for a limited oral evaluation, and an intraoral periapical radiographic image. You say that you should not have to pay for any charges. The Plan denied your request. The Plan says the intraoral periapical radiographic image is a covered benefit, but you have exceeded the frequency limit of one every calendar year. The limited oral evaluation is not a covered service.

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. 

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a limited oral evaluation, and an intraoral periapical radiographic image have not been met. Specifically, the record shows that you had exceeded the frequency limit for the intraoral periapical radiographic image. Additionally, a limited oral evaluation is not a covered benefit. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140), and an intraoral periapical radiographic image (D0230) provided on April 7, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health services.

You asked the Plan to pre-approve home health services. 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 must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.

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 home health services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records do not show that skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve your condition, or to establish/perform a maintenance program to maintain your condition and/or prevent deterioration. The records do not show that skilled therapy services are required to effectively provide treatment, care, and/or services in order to improve your level of function, or to establish/perform a maintenance program to maintain your level of function and/or prevent deterioration. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health services.