Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for lenses (V2303, V2782 x2), deluxe lens feature (V2702 x2), progressive lens (V2781), and anti-reflective coating (V2750 x2) received on December 7, 2020.

You asked the Plan to pay an additional amount for lenses, deluxe lens feature, progressive lens, and anti-reflective coating. You say that you want the Plan to pay an additional amount for these items. The Plan denied your request. The Plan says the benefits were applied correctly. The benefit allowance of $300 was applied to the purchase leaving a member responsibility of $370.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services up to a $300 allowance, then you are responsible for paying the difference.

We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of lenses, deluxe lens feature, progressive lens, and anti-reflective coating have not been met. Specifically, the record shows that you had exhausted your eyewear benefit maximum of $300 and are therefore, responsible for paying the remainder of $370. Therefore, we decided that the Plan does not have to pay an additional amount for lenses (V2303, V2782 x2), deluxe lens feature (V2702 x2), progressive lens (V2781), and anti-reflective coating (V2750 x2) received on December 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown (D2750) provided on December 15, 2020.
You asked the Plan to pay for the crown. You say that your EOC says the Plan will pay 50% for this service. The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan. The Plan also says that the crown (D2750) is covered only with the additional purchase of the Platinum Dental Rider Plan.
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 crown (D2750) provided on December 15, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a physical therapy visit (97161) provided January 28, 2021.
You asked the Plan to waive the copayment for the physical therapy visit. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct copayment was 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 $35 copayment for Therapy Services. You have been asked to pay a $35 copayment for the physical therapy visit. The physical therapy visit falls within the Therapy 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 a physical therapy visit (97161) provided January 28, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the glossectomy billed for services provided on September 2, 2020.
You asked the Plan to pay for the services provided. You say that the documentation supports the billed code. The Plan denied your request. The Plan says the code is not supported in the documentation.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code 41120 is glossectomy; less than one-half tongue. We find that CPT code 41120 is not supported in the medical record. The medical records provided do not indicate the billed service was performed. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the glossectomy billed for services provided on September 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the retreatment of previous root canal therapy provided on January 14, 2021 by a Medicare opt out provider.

You asked the Plan to pay for the retreatment of previous root canal therapy. You say that your dentist referred you to this provider. You also say that your plan does not offer any endodontists in your area. The Plan denied your request. The Plan says the treating provider opted out of Medicare effective August 7, 2018, to August 7, 2022. The Plan also says that services performed by a privately contracted provider are not covered.

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 covered when they are received by a provider who has opted out of Medicare. Therefore, we decided that the Plan does not have to pay for the retreatment of previous root canal therapy provided on January 14, 2021 by a Medicare opt out provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the debridement service (11043) provided
on October 2, 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
$250.00 copay per visit for Medicare-covered surgical, IV therapy, and blood transfusion services.
You have been asked to pay a $250 copayment for the outpatient surgery 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 debridement service (11043) provided on October 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic continuous glucose monitor provided October
19, 2020.
You asked the Plan to pay for the therapeutic continuous glucose monitor. You say that you would like this
claim reprocessed and approved for payment. The Plan denied your request. The Plan says the enrollee was
contacted through an unsolicited phone call which is not eligible for payment.
The Plan must follow Medicare rules. Medicare rules say that a DME supplier may not contact an individual
with an unsolicited phone call.
We looked at the file and Medicare rules. In this case, the Plan has attested that the enrollee was contacted via
an unsolicited phone call regarding the provision of the item at issue. Based on this information, we decided
that Medicare rules for coverage of the therapeutic continuous glucose monitor have not been met. Therefore,
we decided that the Plan does not have to pay for the therapeutic continuous glucose monitor provided October
19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for hearing aids provided on
October 1, 2020.
You asked the Plan to pay an additional amount for the hearing aids. The Plan denied your request. The Plan
says the Plan has reimbursed the full network amount of $750.
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 out-of-network at 50% of the cost for 2 hearing aid (s) every year.
We looked at the file and the Plan's rules. The file shows that the Plan has paid the correct network amount for
the hearing aids. Therefore, we decided that the Plan does not have to pay an additional amount for hearing aids
provided on October 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete maxillary denture and complete mandibular denture provided on January 12, 2021.
You asked the Plan to pay for the complete maxillary denture and complete mandibular denture. You say that you believe the dentures should be covered. The Plan denied your request. The Plan says these services are not covered. The Plan also says that you did not contact the Plan prior to this date of service to verify your benefits.
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 complete maxillary denture and complete mandibular denture provided on January 12, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the infectious agent detection (87798) provided on March 4, 2020.

You asked the Plan to pay for the infectious agent detection. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says Medicare does not provide coverage for predictive screening tests.

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 test at issue in this appeal, the infectious agent detection, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Additionally, there is insufficient clinical information to determine if this testing was medically necessary or why the testing was ordered. Therefore, we decided that the Plan does not have to pay for the infectious agent detection (87798) provided on March 4, 2020.
Appeal type: Drugs
Decision: Unfavorable

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

We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency
transport, (A0428, A0425) provided on October 5, 2020.

You asked the Plan to pay for the ambulance service, basic life support, non-emergency transport,
(A0428, A0425). The Plan denied your request. The Plan says an outpatient cancer treatment center for a
scheduled appointment is not a covered destination.

Medicare pays for ambulance services only when they are medically reasonable and necessary. 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 ambulance service, basic life support,
non-emergency transport, (A0428, A0425). Our reviewer says that the ambulance service was not necessary.
Our physician reviewer found that in this case, the enrollee has metastatic cancer and was transported to
radiation treatment. The medical records submitted do not support that other methods of transportation were
contraindicated. The elements of the coverage rules are not satisfied. The requested service cannot be
recommended. 

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 ambulance service, basic life support, non-emergency transport, (A0428, A0425) have not been met. Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport, (A0428, A0425) provided on October 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 2 power wheelchair.

You asked the Plan to pre-approve a group 2 power wheelchair. You say that this request is medically necessary. The Plan denied your request. The Plan says the criteria for this power wheelchair have not been met.

The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 

The file shows that your condition can be improved by a walker, cane or manual wheelchair. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 2 power wheelchair.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray rendered on November 11, 2019.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says procedure code 73502 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 73502 is radiologic examination, hip, unilateral, with
pelvis when performed; 2-3 views.

We find that CPT code 73502 is not supported in the medical record. Specifically, there is no documentation of a unilateral radiological exam of the hip and pelvis. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the x-ray rendered on November 11, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on January 12, 2021.
You asked the Plan to pay for the physician's services. 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 did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on January 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion Interspinous device for the enrollee.

You asked the Plan to pre-approve these services. You say that this is medically necessary. The Plan denied your request. The Plan says that this device is not indicated for the enrollee.

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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The Vertiflex device remains experimental. More research is needed to show safety and efficacy of the device. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion Interspinous device for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental surgery services provided on September 2, 2020.

You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says this is not a covered service.

Medicare generally does not cover dental services. The Plan follows the same rule. 

The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the dental surgery services provided on September 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the vascular ultrasound guidance (76937) provided on December 1, 2020.

You asked the Plan to pay for the vascular ultrasound guidance. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this service has not been reported with an appropriate primary procedure code.

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, we have confirmed that code the vascular ultrasound guidance is a Type II add-on code and cannot be paid as billed. A Type II add-on code is eligible for payment if an acceptable primary procedure code as determined by the claims processing contractor is also eligible for payment This code cannot be paid as a separate line item. The record shows that CPT code 76973 has not been billed with an appropriate primary procedure code. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the vascular ultrasound guidance (76937) provided on December 1, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapy services provided from October 2, 2020 to October 30, 2020.

You asked the Plan to pay for the therapy services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.

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 the therapy services are not supported in the medical record. Specifically, the claim was not submitted with the required modifier to process and pay claim, which caused the claim to deny. Claim was billed with 440 Rev Code without an appropriate modifier. Per Medicare guidelines a GN modifier are required for rev code 440. This means the Medicare rule for payment of this claim has not been met. Based on this information, we decided that Medicare rules for coverage of the therapy services have not been met. Therefore, we decided that the Plan does not have to pay for the therapy services provided from October 2, 2020 to October 30, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services provided on November 9, 2020.
You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
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 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 ambulance services provided on November 9, 2020.