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

We decided that the Plan does not have to pre-approve additional electrode pads for transcutaneous electrical nerve stimulation (TENS) unit.
You asked the Plan to pre-approve additional electrode pads. You say that you feel you should receive more pads. You also say that you are on a fixed income and cannot afford to pay for additional pads. The Plan denied your request. The Plan says the requested items 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 additional electrode pads. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation indicates that the Plan has provided you with the maximum amount of TENS Unit Supplies. There is no documentation provided indicating that is medically necessary for you to receive additional electrode pads. The documentation indicates that you already received the maximum electrode pads necessary. Therefore, you do not meet criteria for the requested items.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional electrode pads have not been met. Therefore, we decided that the Plan does not have to pre-approve additional electrode pads for transcutaneous electrical nerve stimulation (TENS) unit.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ground mileage (A0425) and emergency ambulance transport (A0427) provided on December 9, 2020.

You asked the Plan to pay for the ground mileage and emergency ambulance transport. You say that the ambulance service was medically necessary. The Plan denied your request. The Plan says the information provided at the time of the appeal does not support medical necessity for ambulance transport.

Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules.

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 ground mileage and emergency ambulance transport. Our reviewer says that the ambulance transport did not meet coverage criteria. Our physician reviewer found the enrollee's presenting symptoms did not meet prudent layperson criteria for emergency care. The documentation did not support that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated for this enrollee on December 9, 2020. Our reviewer found that the documentation did not support that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped ambulance can provide for safe transport. Our physician reviewer also found that the documentation did not support that the ambulance transport was medically reasonable and necessary for the enrollee.

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 ground mileage and emergency ambulance transport have not been met. Therefore, we decided that the Plan does not have to pay for the ground mileage (A0425) and emergency ambulance transport (A0427) provided on December 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit coded 99214 provided on December 30, 2020.
You asked the Plan to pay for the office visit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.
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 99214 is office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 25 minutes are spent face-to-face with the patient
and/or family. We find that CPT code 99214 is not supported in the medical record. Specifically, this service was billed with place of service 12 (home). This code is inappropriately billed when billed with the home place of service. Based on this information, we decided that Medicare rules for coverage of the office visit have not been met. Therefore, we decided that the Plan does not have to pay for the office visit coded 99214 provided on December 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral - periapical each additional radiographic image (D0230 x 5), the unspecified periodontal procedure (D4999), the drugs or medicaments dispensed in the office for home use (D9630), the oral hygiene instructions (D1330), and the gingival irrigation - per quadrant (D4921 x4) received January 20, 2021.
You asked the Plan to pay for the dental services (D0230 (x5), D4999, D9630, D1330, D4921(x4)). You say that the prices quoted by the dental provider have been different for different people. The Plan denied your request. The Plan says some of the services are not covered under your benefit. You have exceeded the frequency limitation for the intraoral - periapical radiographic image.
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 either in excess of, or not among those covered under this benefit. The Plan does not provide coverage for procedure codes D1330, D4921, D4999, and D9630. The Plan limits coverage of intraoral periapical radiographic images to one procedure per calendar year. The Plan has submitted evidence that you exhausted this benefit on the date of service in question. Therefore, we decided that the Plan does not have to pay for the intraoral - periapical each additional radiographic image (D0230 x 5), the unspecified periodontal procedure (D4999), the drugs or medicaments dispensed in the office for home use (D9630), the oral hygiene instructions (D1330), and the gingival irrigation - per quadrant (D4921 x4) received January 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the periodic oral evaluation (D0120) and the set of
4 bitewing x-rays (D0274) provided on January 21, 2021.
You asked the Plan to reimburse you for the oral evaluation and bitewing x-rays. You say that the services
should be covered. The Plan denied your request. The Plan says oral exams are limited to once every 6 months.
The Plan says that dental x-rays are limited to once every 1 or 3 years. The Plan also says that the frequency
limits have been exceeded.
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 the services are listed as covered,
the frequency limits have been exceeded. The record shows that the Plan paid for a comprehensive oral
evaluation and 4 bitewing x-rays performed on August 8, 2020. Therefore, we decided that the Plan does not
have to reimburse you for the periodic oral evaluation (D0120) and the set of 4 bitewing x-rays (D0274)
provided on January 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an eye examination provided on June 11, 2020.

You asked the Plan to waive the copayment for eye exam. You say that you did not request any service other than the annual eye exam, which has not had a copayment before. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.

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 $40 copayment for eye exam. The record shows that this exam addressed a non-routine eye condition, therefore the Medicare-covered medical eye exam copayment applies to this claim. 

You have been asked to pay $40 copayment for eye exam. Eye exam falls within the Vision 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 an eye examination provided on June 11, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the doctor at your hospital wants you to go home to continue therapy, but you do not feel you are well enough to go home and require additional care. The Plan denied your request. The Plan says an IRF is not necessary; the required care can be provided at a lower level, such as a skilled nursing facility.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of your nursing, medical and rehabilitation needs does not require
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Medically necessary services can be provided in a different level of care. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a walker provided on October 20, 2020, through an out-of-network provider.
You asked the Plan to pay for a walker. You say that the item should be covered. The Plan denied your request. The Plan says participating providers must be used.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must 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 a walker provided on October 20, 2020, through an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided by an out-of-network provider on January 5, 2021.
You asked the Plan to pay for the office visit. You say that the provider is employed by the hospital to serve a variety of medically necessary functions. You say that if the hospital is an authorized provider then any service rendered by the house provider would be included in that authorization and the denial should be waived. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the service was not approved in advance.
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 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 office visit provided by an out-of-network provider on January 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aid (V5261) received January 4, 2021 from the out-of-network hearing vendor.
You asked the Plan to pay for the hearing aid. You say that you were disappointed with the selection available inside the Plan's hearing vendor network. The Plan denied your request. The Plan says you must see a Plan provider to use the hearing benefit.
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 when purchased through a Plan provider. We looked at the file, and the Plan's rules. The Plan contract clearly states that you must purchase your hearing aids through the Plan's hearing vendor network. You purchased your hearing aid from a non-Plan hearing vendor. Based on this information, we decided that the Plan's rules for coverage of the hearing aid have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aid (V5261) received January 4, 2021 from the out-of-network hearing vendor.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyelid surgery services provided on November 4, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the eyelid surgery services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.
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 eyelid surgery services provided on November 4, 2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulatory surgical services provided on November 4, 2019 by an out of network (OON) provider.
You asked the Plan to pay for ambulatory surgical services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.
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 ambulatory surgical services provided on November 4, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a dialysis procedure (90999) provided on July 28, 2020.
You asked the Plan to pay for a dialysis procedure. You say that the billed diagnosis is supported. The Plan denied your request. The Plan says this cannot be paid as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The rules also say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. We find that CPT code 90999 is not supported in the medical record. Specifically, medical records documenting this service have not been submitted. Without this information, this code cannot be verified. The records show that the Plan made several attempts to obtain this information without success. Based on this information, we decided that Medicare rules for coverage of a dialysis procedure have not been met. Therefore, we decided that the Plan does not have to pay for a dialysis procedure (90999) provided on July 28, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a lesion removal (11646) provided on December 3, 2020.
You asked the Plan to pay for a lesion removal. You say that this is supported in the medical records. The Plan denied your request. The Plan says this code is not documented.
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 11646 is excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter over 4.0 cm. We find that CPT code 11646 is not supported in the medical record. Specifically, the submitted medical records do not documented that the excision performed had a diameter greater than 4 centimeters. Based on this information, we decided that Medicare rules for coverage of a lesion removal have not been met.
Therefore, we decided that the Plan does not have to pay for a lesion removal (11646) provided on December 3, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion/specialty drug administration services coded 99601 and 99602 provided on December 23, 2020.
You asked the Plan to pay for the home infusion/specialty drug administration 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 payable.
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 99601 and 99602 are not supported in the medical record. Specifically, these codes have a status code of "I". A status code of I means that these codes are not valid for Medicare purposes. Medicare uses another code for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for coverage of the home infusion/specialty drug administration services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion/specialty drug administration services coded 99601 and 99602 provided on December 23, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the cost for pathology services provided on November 23, 2020.
You asked the Plan to waive the cost for the pathology services. You say that a cystourethroscopy was performed, and you were not advised of any irregularities or additional tests. The Plan denied your request. The Plan says the cost share applied correctly.
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 your deductible is $250. This is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. Until you have paid the deductible amount, you must pay the full cost for most of your covered services. Your contract with the Plan also says that after your yearly deductible is met you must pay $10 per day, per provider, for Medicare-covered pathology services. The item or service you asked the Plan to waive the cost 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 your $250 deductible applies to outpatient diagnostic services. This cost sharing is a contractual obligation that had not been met at the time the pathology services were received on November 23, 2020. Therefore, $155.30 has been applied to meet your deductible.
Since your $250 deductible was met you have also been asked to pay a $10 copayment. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost for pathology services provided on November 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the excision of Bartholin's gland or cyst services coded 56740 provided on September 24, 2020.

You asked the Plan to pay for the excision of Bartholin's gland or cyst services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.

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 56740 is excision of Bartholin's gland or cyst.

We find that CPT code 56740 is not supported in the medical record. Specifically, this service was billed with place of service 11 (office). This code should never be performed in the office setting. Based on this information, we decided that Medicare rules for coverage of the excision of Bartholin's gland or cyst services have not been met. Therefore, we decided that the Plan does not have to pay for the excision of Bartholin's gland or cyst services coded 56740 provided on September 24, 2020.