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

We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy with polyp removal (CPT code 45385) provided on November 20, 2020, by an in-network provider.
You asked the Plan to waive the copayment for the services. You say that you had a colonoscopy and the doctor cut some polyps out during the procedure. You state you think this should be covered as you were under anesthesia. The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received a diagnostic colonoscopy on November 20, 2020, from an in-network ambulatory surgical center. You were asked to pay a $250 copayment for the services. Your 2020 EOC states that enrollees must pay a $250 copayment for each Medicare-covered in-network ambulatory surgical center 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 waive the copayment for a diagnostic colonoscopy with polyp removal (CPT code 45385) provided on November 20, 2020, by an in-network provider
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) and the emergency ambulance transport (A0427), ground mileage (A0425), oxygen in a life sustaining situation (A0422), and the routine disposable supplies (A0398) provided on December 29, 2020.
You asked the Plan to pay for the ambulance services. You say that the enrollee was transported from urgent care to the hospital by the Fire Department. You say that the Ambulance service did not transport you. You say that you are being billed $581 from one provider and $150 from the other for the same transport service. You also say that you should not be billed for the same transport twice. The Plan denied your request. The Plan says there is a $150 copayment for covered ambulance services. The Plan says that they confirmed with the provider that you were transported by the Ambulance Services on the date of service in this case. The Plan also says that payment may be made only to the ambulance provider that furnishes the transport.
The Plan must follow Medicare rules. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $150 copayment for ambulance services. The rules also say that Medicare does not pay for ambulance services when there is no transport. The enrollee has been asked to pay a $150 copayment for the ambulance services. The ambulance services provided fall within the ambulance services benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. The Fire Department did not provide transport services on December 29, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998), provided by the Fire Department provided on December 29, 2020. We also decided that the Plan does not have to waive the cost share for the emergency ambulance transport (A0427), ground mileage (A0425), oxygen in a life sustaining situation (A0422), and the routine disposable supplies (A0398) provided on December 29, 2020.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an advanced foot and ankle, a prosthetic leg, and other parts related to these items.

You asked the Plan to pre-approve an advanced foot and ankle, a prosthetic leg, and other parts related to these items. You say that the enrollee is in a lot of pain without the foot. The appellant says that the enrollee has a unlevel yard. You say that the requested items would help maintain the skin because of rubbing. The Plan denied your request. The Plan says the medical record provided does not support that the enrollee is a K3 ambulator. The Plan says that there is no clear documentation as to why the requested part is needed.

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 an advanced foot and ankle, a prosthetic leg, and other parts related to these items. Our reviewer says that an advanced foot and ankle, a prosthetic leg, and other parts related to these items are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested items exceed the enrollee's functional need. The documentation from the physician does not support that the enrollee is a K3 ambulator given the enrollee's comorbidities including fatigue, chronic back pain and use of 2 canes for balance. Furthermore, the vendor notes that expected ambulatory aides include cane/crutches, wheelchair and 4WW which is not consistent with K3 ambulation.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an advanced foot and ankle, a prosthetic leg, and other parts related to these items have not been met. Therefore, we decided that the Plan does not have to pre-approve an advanced foot and ankle, a prosthetic leg, and other parts related to these items.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve combination sit to stand frame/table system, any size
including pediatric, with seat lift feature, with or without wheels (CPT code E0637).

You asked the Plan to pre-approve the item. You say that you asked for a standing frame/table because of
problems standing without support. The Plan denied your request. The Plan says a standing frame/table is not
for a medical problem and makes it easier to stand. The Plan states neither Medicare nor your health plan
covers this.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured.

Therefore, we decided that the Plan does not have to pre-approve combination sit to stand frame/table system,
any size including pediatric, with seat lift feature, with or without wheels (CPT code E0637).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on September 16, 2020.
You asked the Plan to pay this claim. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says due to the enrollee's hospice election at the time of service, this claim should be submitted to Original Medicare first.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The documentation shows the enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on September 16, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy provided from October 6, 2020, through October 20, 2020.
You asked the Plan to waive the copayment for physical therapy. You say that you were informed the coverage with no copayment was extended through October, so you made more appointments. You say that you want the bill resolved. 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 $40 copayment for each Medicare-covered physical therapy and speech-language therapy visit.
You have been asked to pay a $40 copayment for each physical therapy visit. The total amount you owe is $320 ($40/visit x 8 visits = $320). Physical therapy falls within the "Outpatient Rehabilitation Services" benefit category. The Plan says the cost share waiver was only through September 30, 2020. 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 provided from October 6, 2020, through October 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit (99212) and destruction of precancer skin growth (17000) provided April 12, 2021.

You asked the Plan to waive the copayment for the office visit and destruction of precancer skin growth. You say that you would like this copayment waived. The Plan denied your request. The Plan says the cost share has processed 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 $40 copayment for physician specialist services. 

You have been asked to pay a $40 copayment for the office visit and destruction of precancer skin growth. These services fall within the physician specialist 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 office visit (99212) and destruction of precancer skin growth (17000) provided April 12, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRI provided on March 25, 2021.
You asked the Plan to waive the copayment for an MRI. You say that you feel that the Plan should cover the charges. The Plan denied your request. The Plan says the claims were processed correctly, and you are being charged the correct 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 $100 copayment for MRI's.
You have been asked to pay a $100 copayment for an MRI. An MRI falls 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 copayment for an MRI provided on March 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140), the root canal (D3310), and the treatment of a root canal obstruction (D3331) provided on March 31, 2021.
You asked the Plan to pay for the dental services. You say that the dental services you received were denied. You also say that you do not understand why you have dental insurance if nothing is covered. The Plan denied your request. The Plan says limited oral evaluation is not listed as a covered service.
The Plan says that root canal is not listed as a covered service. The Plan also says that treatment of a root canal obstruction is not listed as a covered service either.
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 dental services you received are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140), the root canal (D3310), and the treatment of a root canal obstruction (D3331) provided on March 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve neurolytic nerve ablation services.

You asked the Plan to pre-approve neurolytic nerve ablation services. You say that the records provided support the need for the requested treatment. The Plan denied your request. The Plan says medical necessity has not been established.

The Plan follows Medicare rules. Medicare rules say that after the first diagnostic facet joint procedure, there must be a consistent positive response of at least 80% relief of primary pain.

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 neurolytic nerve ablation services. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found a consistent positive response of at least 80% was not achieved and therefore, the result is considered negative. There is no indication to proceed with radiofrequency ablation services. The requested services are not considered medically reasonable and 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 neurolytic nerve ablation services have not been met. Therefore, we decided that the Plan does not have to pre-approve neurolytic nerve ablation services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the request is unable to be approved.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 pre-approve the services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found your main diagnosis is debility, and you are medically stable. You have made no progress in short term rehabilitation in the SNF. Your care needs are currently custodial. You do not require daily skilled therapy services on an inpatient basis beyond 7/1/21. A continuation of your stay is not 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued admission to a skilled nursing facility (SNF).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the Vertiflex Superion interspinous device provided on March 16, 2021.
You asked the Plan to pay for Vertiflex Superion interspinous device. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the rendered services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for Vertiflex Superion interspinous device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was being treated for spinal stenosis, lumbar region, with neurogenic claudication. The enrollee presented with low back pain with bilateral buttock and leg pain. 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 as discussed above. Therefore, the enrollee did not meet criteria for the services rendered. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Vertiflex Superion interspinous device have not been met. Therefore, we decided that the Plan does not have to pay for the Vertiflex Superion interspinous device provided on March 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level (CPT code(s): 64493 and 64494), for the enrollee.

You asked the Plan to pre-approve the injections. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are not 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 injections. physician reviewer found
the enrollee has low back pain with associated radiculopathy. The review has determined that the medical
records provided do not meet the requirements listed in the LCD for Medicare coverage.

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 injections have not been met. Therefore, we decided that the Plan does not
have to pre-approve injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or
nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level (CPT
code(s): 64493 and 64494), for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Intracept procedure.

You asked the Plan to pre-approve Intracept procedure. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Intracept procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has low back pain. The intracept procedure remains experimental. More research is needed to show safety and efficacy of the intracept procedure for low back pain treatment. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve Intracept procedure.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (27236, 27299) provided on March 25, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services 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 27236 is "Open treatment of femoral fracture, proximal end, neck, internal fixation or prosthetic replacement". The CPT Code Manual definition of code 27299 is "Unlisted procedure, pelvis or hip joint".
We asked our coding 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 services. Our reviewer says that the use of codes 27236 and 27299 is not supported by the records provided. Our coding reviewer found that the operative report describes total hip arthroplasty and should be reported with a more appropriate code. For code 27299, the documentation does not include a description of procedure performed and no other code exists to report the procedure. We looked at this coder's review, the file, and Medicare rules. 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 (27236, 27299) provided on March 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the re-evaluation of a post-operative office visit (D0171) provided on March 22, 2021.
You asked the Plan to pay for the re-evaluation. You say that you would like this service to be reprocessed and paid as a typical office visit. The Plan denied your request. The Plan says this service is not covered by Medicare or by the Plan's supplemental dental benefit.
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 pay for the re-evaluation of a post-operative office visit (D0171) provided on March 22, 2021.