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

We decided that the Plan does not have to pay for the sedation services provided on January 5, 2020. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says 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 CPT code. 
 
In this case, the CPT Code Manual definition of code 99152 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time. 
 
We find that CPT code 99152 is not supported in the medical record. Specifically, the records do not show that 
an independent trained observer was present during the provided service. Based on this information, we 
decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided 
that the Plan does not have to pay for the sedation services provided on January 5, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic screening testing provided on November 12, 2019. 
 
You asked the Plan to pay for genetic tests. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of payment for this testing is correct, because this testing was not 
billed with the appropriate coding and is non-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 genetic testing at issue in this appeal was requested for screening purposes. Medicare does not cover this 
testing for screening purposes. Therefore, we decided that the Plan does not have to pay for genetic screening 
testing provided on November 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services (A0429) provided 
on July 4, 2020. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you would like this 
copayment waived for a potential wrong code. The Plan denied your request. The Plan says the copayment 
applied correctly in this case. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300 
copayment for ambulance services.  
 
You have been asked to pay a $300 copayment for the ambulance services. The services provided 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 copayment for the 
ambulance services (A0429) provided on July 4, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital services you received 
from April 15, 2020, to April 22, 2020. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you were forcefully 
kept in the hospital, so you don't think you should have to pay this copayment. The Plan denied your request. 
The Plan says you were charged this copayment 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 $393 
copayment per day for days 1-5 for inpatient hospital services.  
 
You have been asked to pay a $393 copayment per day for days 1-5 for the inpatient hospital services, for a 
total of $1,965. This copayment applies regardless of the reason for your inpatient stay. 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 inpatient hospital services you received from April 15, 2020, to April 
22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the immediate denture (D5140) provided on September 14, 
2019. 
 
You asked the Plan to pay for the dental item. You say that you need to have your extractions done with an oral 
surgeon. You say that you had an appointment but had to cancel. You say that since the pandemic hit, it has 
been difficult to find an oral surgeon to do the extractions. You say that you found an oral surgeon and will 
have the extractions done soon. You also say that you cannot afford to pay this bill. The Plan denied your 
request. The Plan says dental items and services that are not necessary are not covered. The Plan says that there 
is no evidence that the extractions have been provided. The Plan also says that if the extractions have not been 
performed, then the immediate denture is not needed. 
 
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 immediate dentures are listed as a 
covered item, the item is not necessary if extractions have not been performed. The record shows that you had 
an appointment to receive extractions but you cancelled, thus not receiving them. The immediate denture is not 
necessary if you still have the teeth that they were meant to replace. Therefore, we decided that the Plan does 
not have to pay for the immediate denture (D5140) provided on September 14, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for general lab tests (80061 and 80053) 
performed on June 5 and June 9, 2020. 
 
You asked the Plan to waive the copayments for general lab tests. You say that the provider informed you that 
you would not be charged for both blood draws. The Plan denied your request. The Plan says the correct 
copayments were 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 $10 
copayment per day for Medicare-covered lab services.  
 
You have been asked to pay two $10 copayments for general lab tests on two dates of service. General lab tests 
fall within the "Outpatient diagnostic tests and therapeutic services and supplies" 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 general lab tests (80061 and 80053) performed on June 5 and June 
9, 2020.  
 
Your complaint about receiving erroneous or ambiguous information regarding cost-sharing from your 
provider 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the intravenous infusions provided from 
August 7, 2019, through August 13, 2019. 
 
You asked the Plan to waive the copayment for the intravenous infusions. The Plan denied your request. The 
Plan says the copayments 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 $395 
copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including 
but not limited to hospital or other facility charges and physician or surgical charges. 
 
You have been asked to pay $178.29, which is less than the standard $395 copayment for each intravenous 
infusion. The total amount you owe is $1,248.03 ($178.29/infusion x 7 infusions = $1,248.03). The intravenous 
infusions fall within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient 
Facilities and Ambulatory Surgical Centers" 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 intravenous infusions provided from August 7, 2019, 
through August 13, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for PET with CT (78815) provided on June 23, 2020. 
 
You asked the Plan to pay for the PET with CT. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the diagnosis code listed on the claim is not 
listed as an acceptable code for this service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT code 78815-26 is not supported in the record. Specifically, CMS provides a list of 
appropriate diagnosis codes for PET for Oncologic Conditions. The diagnosis codes billed, C83.10, D64.9 and 
D69.59 are not on the list of appropriate diagnoses for this service.  Based on this information, we decided that 
Medicare rules for coverage of the PET with CT have not been met. Therefore, we decided that the Plan does 
not have to pay for PET with CT (78815) provided on June 23, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pay forself-administered drugs provided to the enrollee on July 4, 2020.You asked the Planto pay forthe drugs. You say that the enrollee was under no condition to make any decision for treatment due to his health status.The Plandenied your request. The Plansayscovered drugs includeThe 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 Plandoes not haveto pay forself-administered drugs provided to the enrollee on July 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forportable oxygen equipment purchase on June 1, 2020.You asked the Plan to pay forthis equipment. You say that you needed this equipment for travel to andfrom Florida.The Plandenied your request. The Plan says neither the Plan nor Medicare covers portable oxygen equipment for use outside of the home. Neither Medicare nor the Plan covers purchased oxygenequipment.You did not have prior authorization for this equipment. The Plan must follow Medicare rules. The rules say that portable oxygen is only covered by Medicare for use in the home. The rules say that purchase of oxygen equipment is not covered. The rules say that equipment purchased for convenience is not covered. 
You purchased oxygen equipment without prior authorization. You did not follow your Plans contract rules when you purchased this equipment. Therefore, we decided that the Plan does not have to pay forportable oxygen equipment purchase on June 1, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for adjacent tissue transfer or rearrangement (14301) provided on February 11, 2020.
You asked the Plan to pay for adjacent tissue transfer or rearrangement. You say that this was billed appropriately. The Plan denied your request. The Plan says this code 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 adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm. 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 adjacent tissue transfer or rearrangement. Our reviewer says that this code is not supported in the medical record. Our physician reviewer found with an advancement flap, tissue is moved in a straight line and stretched over the defect. This is also referred to as a V-Y repair or flap. The primary defect is usually created from the excision of a benign or malignant lesion. The creation of the primary defect is included in an adjacent tissue transfer and not separately coded. The submitted documentation does not support a separate procedure. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of adjacent tissue transfer or rearrangement have not been met. Therefore, we decided that the Plan does not have to pay for adjacent tissue transfer or rearrangement (14301) provided on February 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvegraft, bone nasal, maxillary/malar areas (includes obtaining graft) (21210) and graft, bone, mandible (includes obtaining graft) (21215) to be provided by an out of network provider.You asked the Plan to pre-approvethe dental services. You say that orthopedic oral implants are medically necessary because first stage digestion is impaired and the enrollee's diet is limited to semisolid or soft foods.The Plan denied your request. The Plan says enrollee's must receive their dental services from an in-network provider.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 health plan contract on page 52, says that care rendered by a provider that is not part of the plan's supplemental dental network is not covered. 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-approvegraft, bone nasal, maxillary/malar areas (includes obtaining graft) (21210) and graft, bone, mandible (includes obtaining graft) (21215) to be provided by an out of network provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Planhasto pre-approvethe Dermagraft skin substitute graft.You asked the Planto pre-approvethe graft. You say that this is medically necessary.The Plandenied your request. The Plansaysthatthis 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 the graft. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found this is medically necessary to avoid complications and the need for more expensive therapies.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 graft have been met.Therefore, we decided that the Planhas to pre-approvethe Dermagraft skin substitute graft.If the Plandoes 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/orsend us the new information. This does not happen often. If we decide toopen the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve paravertebral facet joint destruction.

You asked the Plan to pre-approve the destruction. You say that this is medically necessary. The Plan denied your request. The Plan says there is no documentation of dual medial branch blocks at the requested levels to diagnose facet 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 destruction. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the request is for radiofrequency ablation of six facet joints in the thoracic spine. The enrollee has not had prior medial branch blocks at the requested levels. As well, a maximum of five facet injection sessions inclusive of medial branch blocks and ablations may be performed per rolling 12-month year in the cervical/thoracic spine.

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 destruction have not been met. Therefore, we decided that the Plan does not have to pre-approve paravertebral facet joint destruction.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided to the enrollee from May 25, 2020 through May 28, 2020.
You asked the Plan to pay for the SNF services. The Plan denied your request. The Plan says that the enrollee was receiving comfort measures only.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 pay for the SNF services. Our reviewer says that daily skilled services were not necessary. Our physician reviewer found that the enrollee's condition did not meet Medicare criteria for SNF services.
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 SNF services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided to the enrollee from May 25, 2020 through May 28, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecomputerized dynamic posturography sensory organization test (92548).You asked the Plan to pre-approvecomputerized dynamic posturography. You say that the medical records provided support the necessity of the services in dispute.The Plan denied your request. The Plan says there is insufficient clinical evidence to determine medical usefulness of Computerized Dynamic Posturography (CDP), the study is considered experimental/investigation and not coveredThe Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of computerized dynamic posturogpraphy have not been met.Therefore, we decided that the Plan does not have to pre-approvecomputerized dynamic posturography sensory organization test (92548).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee orthosis (L1833)
You asked the Plan to pre-approve the orthosis. You say that the claim should be paid. The Plan denied your
request. The Plan says the enrollee does not meet Medicare coverage criteria.
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 orthosis. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the enrollee's localized pain is likely due to ligamentous stretching as her varus deformity
worsens, criteria states knee brace for osteoarthritis is indicated when there is 'No injury or chronic stretch of
medial or lateral collateral ligaments or other structures of knee'. The review has determined that the
items/services at issue in this case are 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 orthosis have not been met. Therefore, we decided that the Plan does not
have to pre-approve a knee orthosis (L1833)
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro brace for the enrollee. 
 
You asked the Plan to pre-approve the brace. You say that this is medically necessary. The Plan denied your 
request. The Plan says this device has deluxe features that exceeds the enrollee's needs, and replaces, rather 
than improves the function of the arm. 
 
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 brace. Our reviewer says that the 
requested brace is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the medical records provided do not meet the requirements listed in the Social Security Act, Section 
1862 (a)1(A) and the 42 CFR ?411.15(k) for Medicare coverage for the powered upper extremity range of 
motion assist device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, 
all components and accessories, custom fabricated (L8702). At this time, the requested robotic orthosis is not 
the standard of care or proven to be more beneficial for treatment of the patient's medical condition/function of 
hemiparesis after stroke than any available standard therapy. The requested device is not reasonable and 
necessary for the diagnosis or treatment of an illness or injury or  to improve the functioning of a malformed 
body member. 
 
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 brace have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the MyoPro brace for the enrollee.