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

We decided that the Plan does not have to pay for the chest x-ray rendered to enrollee on April 29, 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 71045 is not separately payable.The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.The provider submitted a claim for procedure codes 71045 and 32555. Code 71045 is a column II code with a modifier indicator of 1 when billed with column I code 32555. Code 71045 was not billed with an appropriate modifier to allow for separate payment.Therefore, we decided that the Plan does not have to pay for the chest x-ray rendered to enrollee on April 29, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for Dental services (D4910, D0120, D0274, D1206) provided
October 16, 2019.
You asked the Plan to pay for the dental services. You say that the services should be covered. The Plan denied
your request. The Plan says at the time services were rendered, the provider was not enrolled in the Medicare
program.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
We looked at this physician's review, the file, and Medicare rules. The doctor was not enrolled in the
Medicare program at the time services were provided. Based on this information, we decided that the Plan's
rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does not have
to pay for Dental services (D4910, D0120, D0274, D1206) provided October 16, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics (L3010).
You asked the Plan to pre-approve foot orthotics. You say that foot orthotics are medically necessary for the continued care of your surgically repaired foot. The Plan denied your request. The Plan says these items are not a covered benefit under your contractual policy for your condition.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics (L3010).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Artificial leg with advanced foot and knee features.
You asked the Plan to pre-approve the prosthesis. You say that the prosthetic limb with advanced features is medically necessary. The Plan denied your request. The Plan says the prosthesis is medically necessary, however there are in-network providers who can provide the items and services requested.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve an Artificial leg with advanced foot and knee features.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a Canalith repositioning procedure (95992) provided on October 1, 2019.
You asked the Plan to pay for the procedure. You say that the service was medically necessary. The Plan denied your request. The Plan says the service was not billed with an approved diagnosis code.
The Plan must follow Medicare rules. Medicare rules say that Canalith repositioning procedures (CPT Code 95992) are only covered for a diagnosis of Benign Paroxysmal Vertigo. We looked at the file and Medicare rules. The record does not show that the claim was submitted with a diagnosis of Benign Paroxysmal Vertigo listed. Based on this information, we decided that Medicare rules for coverage of the procedure have not been met. Therefore, we decided that the Plan does not have to pay for a Canalith repositioning procedure (95992) provided on October 1, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that you took medication for your allergies and your blood pressure raised. You say that you called for an ambulance and after the responders treated you, your blood pressure went down. You stated that they told you that you did not have to go to the hospital if you did not want to. You felt better and your blood pressure had gone back down, so you decided not to go to the hospital. You say that you were given the run around and that the Plan should pay for the services. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on September 18, 2019. 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 services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy services. You asked the Plan to pre-approve the physical therapy services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care or if the same or similar services cannot be provided with an in-network provider, which requires prior authorization from the plan. 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physical therapy services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental cleaning (D1110) provided November 26, 2019.
You asked the Plan to pay for the dental cleaning. You say that you are being denied your third cleaning and you are paying extra for this plan. You are on a fixed income and you need a deep cleaning 3 to 4 times a year or you will have problems with your gums. The Plan denied your request. The Plan says this service exceeds the benefit maximum of twice a year.
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 dental cleaning (D1110) provided November 26, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay forthe acute inpatient hospital care provided June 1, 2019 to June 3, 2019.You asked the Plan to pay forthe acute inpatient hospital care. You say that you are requesting a reconsideration of the Plan's denial for payment as the inpatient hospital care provided was medically necessary.The Plan denied your request. The Plan says that the inpatient hospital care provided was not medically necessary.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found that the enrollee presentedto the Emergency Department (ED)on June 1, 2019with complaints of increased shortness of breathand increasing lower extremity edema. On evaluationhe was hypertensive,and the physicalexam was notable for rhonchi as well as lower extremity edema. The chest x-raydemonstrated congestive heart failureand the electrocardiogramwas without any acute ischemic changes. He was treated with supplemental oxygenand IV Lasix. He was admitted to telemetry. The enrolleeunderwent continued diuresis and his condition stabilized and improved. He was then discharged home on June 3, 2019when he was considered medically stable. The review has determined that  the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights.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 acute inpatient hospital care have been met.Therefore, we decided that the Plan has to pay forthe acute inpatient hospital care provided June 1, 2019 to June 3, 2019.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide toopen the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ankle braces and accessories (L1907 x 2, L2270 x 2, L2275 x 2, L2820 x 2)
You asked the Plan to pre-approve the durable medical equipment. You say that the durable medical equipment should be covered. The Plan denied your request. The Plan says the enrollee does not meet coverage criteria.
The Plan follows Medicare rules. Medicare rules say that inserts and other shoe modifications are covered if they are on a shoe that is an integral part of a covered brace and if they are medically necessary for the proper functioning of the brace. 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 durable medical equipment. Our reviewer says that is not medically necessary. Our physician reviewer found the documentation does not reveal objective findings of weakness or instability on a physical exam of the lower extremities. The request for custom molded inserts (L3000 x 2, L3390 x 2) is not medically necessary as the documentation does not reveal that the inserts are on a shoe that is an integral part of a covered brace and that they are medically necessary for the proper functioning of the brace. 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 durable medical equipment have not been met. Therefore, we decided that the Plan does not have to pre-approve ankle braces and accessories (L1907 x 2, L2270 x 2, L2275 x 2, L2820 x 2)
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered to the enrollee on October 23, 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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 drug testing rendered to the enrollee on October 23, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the Rivaroxaban provided on August 19, 2019.
You asked the Plan to pay for this drug. You say that this was given to you by the nurse. The Plan denied your request. The Plan says that this is not a Part B covered drug.
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 pay for the Rivaroxaban provided on August 19, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forarthrocentesis provided by an outpatient hospital facility on November 5, 2019.You asked the Plan to waive the copayment forarthrocentesis. You say that you feel that the charges are too high and you should not be responsible for 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 $250 copayment for surgery services provided at an outpatient hospital facility. You received arthrocentesis at an outpatient hospital facility on November 5, 2019. Arthrocentesis is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $250 copayment. You have been asked to pay a $250 copayment for arthrocentesis. Arthrocentesis falls within the outpatient surgery, including 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 thePlan does not have to waive the copayment forarthrocentesis provided by an outpatient hospital facility on November 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve parenteral nutrition solution (B4185, B4189, B4193, B4197, B4199, B4224).
You asked the Plan to pre-approve parenteral nutrition solution. You say that this is medically necessary because you are malnourished due to poor appetite and as a side effect of your dialysis. The Plan denied your request. The Plan says this is not covered because you are able to take food orally.
The Plan must follow Medicare rules. Medicare rules say that parenteral nutrition is considered reasonable and necessary for a patient with severe pathology of the alimentary tract which does not allow absorption of sufficient nutrients. We looked at the file and Medicare rules. The record does not show that you have any problems with your alimentary tract. Based on this information, we decided that Medicare rules for coverage of parenteral nutrition solution have not been met. Therefore, we decided that the Plan does not have to pre-approve parenteral nutrition solution (B4185, B4189, B4193, B4197, B4199, B4224).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 95999 provided on August 13, 2019.
You asked the Plan to pay for CPT code 95999. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
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 95999 is unlisted neurological or neuromuscular diagnostic procedure. We find that CPT code 95999 is not supported in the medical record. Specifically, the record shows that train of four testing was performed and this is not the appropriate code for this service. Per Medicare guidelines, it is inappropriate to bill unlisted neurological or neuromuscular diagnostic CPT codes for train of four monitoring. There is no separate code for train of four monitoring. Based on this information, we decided that Medicare rules for coverage of CPT code 95999 have not been met. Therefore, we decided that the Plan does not have to pay for CPT code 95999 provided on August 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for acupuncture services (97810) provided on September 16, 2019 through September 24, 2019.
You asked the Plan to waive the copayment for the acupuncture services. You say that you would like reimbursement for two checks that were stopped by the Plan as well as the additional $40 you incurred in fees. The Plan denied your request. The Plan says the claims for these services have been reprocessed and paid, but the additional fees remain upheld.
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 $20 copayment for Acupuncture services. You have been asked to pay a $20 copayment for the acupuncture services. The acupuncture services fall within the Acupuncture 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 acupuncture services (97810) provided on September 16, 2019 through September 24, 2019.
Your complaint about additional fees incurred from the cancelled checks 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on August 21, 2019.You asked the Plan to pay forthe orthosis. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay fora knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on August 21, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for PT provided from July 1, 2019 to July 31, 2019.
You asked the Plan to waive the copayments for PT. You say that the PT should be considered home health visits with no copayment. The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $25 copayment for outpatient rehabilitation services. The record shows that the enrollee received PT services from July 1, 2019 to July 31, 2019 for a total of 8 sessions. Therefore, the enrollee is responsible to pay a $25 copayment per each session. The total amount the enrollee owes is: $25 (copayment) x 8 (PT sessions) = $200. The enrollee has been asked to pay the total copayment amount of $200 for PT. PT falls within the outpatient rehabilitation 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. Therefore, we decided that the Plan does not have to waive the copayments for PT provided from July 1, 2019 to July 31, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on November 8, 2019.
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on November 8, 2019.