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

We decided that the Plan does not have to waive the coinsurance for the Hyaluronan injection (CPT code J7318) provided on October 26, 2020.
You asked the Plan to waive the coinsurance for the injection. You say that you are appealing your cost-share responsibility for the services you received. 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 Hyaluronan injection on October 26, 2020. You have been asked to pay 20% coinsurance of the allowed amount for the injection. The allowed amount is $6,699. The total you owe is $1,339.80 ($6,699 x 20% = $1,339.80). Your 2020 EOC says that enrollees must pay 20% of the cost for Part B covered chemotherapy drugs and 20% of the cost for other Part B covered drugs. 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 coinsurance for the Hyaluronan injection (CPT code J7318) provided on October 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140 x 2), the periapical x-ray (D0220 x 2), the root canal (D3330 x 2), and the unspecified preventive service (D1999 x 2) provided from December 3, 2020, to January 19, 2021.
You asked the Plan to pay for the dental services. You say that you are recovering from MMP over the last 5 years. You say that this provider is the only one that can assist as he has been treating and improving the wellness of your gums. You also say that it is not fair that you are unable to see an out of network dentist when this dentist has been following you and treating you post MMP. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that dental services performed out of network are not covered. The Plan also says there are participating endodontists in your area.
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, dental services performed out of network 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 x 2), the periapical x-ray (D0220 x 2), the root canal (D3330 x 2), and the unspecified preventive service (D1999 x 2) provided from December 3, 2020, to January 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the compression stockings.
You asked the Plan to pre-approve the compression stockings. You say that this request is medically necessary.
The Plan denied your request. The Plan says this item is non-covered
The Plan must follow Medicare rules. Medicare rules say that compression stockings are covered only when
they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and
gradient compression wraps are covered only when they are used as dressings over a qualifying wound.
The record does not show that the enrollee has open venous stasis ulcers or a qualifying wound. This means
that the enrollee does not have a medical condition for which compression stockings can be covered or paid for
by Medicare. Therefore, we decided that the Plan does not have to pre-approve the compression stockings.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair accessory, electronic connection between wheelchair controller and two or more power seating system motors.
You asked the Plan to pre-approve a power wheelchair accessory, electronic connection between wheelchair controller and two or more power seating system motors. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that expandable controllers are covered under specific circumstances. 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 a power wheelchair accessory, electronic connection between wheelchair controller and two or more power seating system motors. Our reviewer says that the items are not medically necessary. Our physician reviewer found the documentation does not support that the enrollee needs to control 2 or more motors (such as proportional joystick, touchpad, or non-proportional interface) from a single interface. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a power wheelchair accessory, electronic connection between wheelchair controller and two or more power seating system motors have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair accessory, electronic connection between wheelchair controller and two or more power seating system motors.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a specialist physician office visit (99202) to be provided by an OON provider.
You asked the Plan to pre-approve a specialist office visit. You say that the requested services are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for OON care have not been met.
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 a specialist physician office visit (99202) to be provided by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower denture (D5120).
You asked the Plan to pre-approve the dentures. You say that these services are necessary. The Plan denied your request. The Plan says dentures are not covered under 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 pre-approve a complete upper denture (D5110) and a complete lower denture (D5120).
Please note: The Plan offers a supplemental Flex benefit that can offer up to $400 of reimbursement per year for additional dental services or other non-Medicare-covered healthcare items. Contact the Plan to learn more about how to use this Flex benefit and if it may be used toward a purchase of dentures.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation mileage.

You asked the Plan to pre-approve additional routine transportation mileage. You say that you are requesting additional mileage for your transportation to your doctor visit. The Plan denied your request. The Plan says this request exceeds the amount of mileage allowed per your benefits.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. The mileage between the requested pickup, and destination locations is two hundred sixty-one (261) miles. The Plan states this request exceeds the amount of mileage allowed per your benefits. Your 2021 EOC says each one-way trip must not exceed fifty (50) miles of driving distance. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation mileage.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of home health skilled nursing services
(G0299, G0300).
You asked the Plan to pre-approve the continuation of home health skilled nursing services. You say that
continued home health skilled nursing care is medically necessary. The Plan denied your request. The Plan says
home health skilled care is no longer medically necessary.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.
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 continuation of home health skilled
nursing services. Our reviewer says that the requested home health care is not medically necessary and
reasonable. Our physician reviewer found that the enrollee is a 66-year-old woman with a history of
hypertension, peripheral vascular disease, sleep apnea, and colon cancer. The available documentation in the
case file does not support that continued skilled nursing services are required to effectively provide treatment,
care, and/or services in order to improve the enrollee's condition, or to establish/perform a maintenance
program to maintain the patient's condition and/or prevent deterioration.
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 continuation of home health skilled nursing services have not been met.
Therefore, we decided that the Plan does not have to pre-approve the continuation of home health skilled
nursing services (G0299, G0300).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for antibody; severe acute respiratory syndrome coronavirus 2
(SARS-CoV-2) (Coronavirus disease [COVID-19]) (CPT code 86769) provided on July 15, 2020.

You asked the Plan to pay for the services. You say that after initially testing positive for COVID-19 and
quarantining for ten (10) days you had to be tested two (2) additional times, the first time testing positive again,
and the second testing negative. You state you already submitted your claims form and receipts for each test.
The Plan denied your request. The Plan says a receipt was received for the first date of service, July 6, 2021,
and payment was issued to you for that date, however, no documentation has been submitted for the second
service on July 15, 2021.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.

Based on this information, we decided that Medicare rules for coverage of the services have not been met. The
claim for date of service July 15, 2020, denied correctly as no receipt, or cost breakdown of the services
provided was received by you for this date. Therefore, we decided that the Plan does not have to pay for
antibody; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19])
(CPT code 86769) provided on July 15, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services rendered from March 22, 2020 to April 2, 2020.

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 the records do not support the billed DRG and diagnosis code.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.

In this case, you billed the inpatient services provided with DRG 871 and diagnosis code A41.9 (sepsis, unspecified organism). 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 these services. Our reviewer says that the records do not support the billed DRG and diagnosis code. Our physician reviewer found the enrollee was admitted to the hospital with atrial fibrillation and dyspnea. The white blood count was normal, there was no left shift, and the impression was volume overload. An elevated white blood cell count developed during the admission. The enrollee ultimately developed mental status changes, was found to have an acute cerebrovascular accident and passed away. The record supports that the chief reason for admission was the hypoxic failure. DRG 871 and diagnosis code A41.9 cannot be recommended. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services rendered from March 22, 2020 to April 2, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Superion interspinous spacer for the enrollee.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that this service is considered experimental and investigational.
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 superion spacer 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. 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 Superion interspinous spacer for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the Proair inhaler (A9270) and the Doxycycline medication (A9270) provided on October 18, 2020.
You asked the Plan to pay for these medications. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that self-administered drugs provided in an outpatient hospital setting are not covered.
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 provided 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 Proair inhaler (A9270) and the Doxycycline medication (A9270) provided on October 18, 2020.
Benefits for this medication may be available under Medicare Part D. You may contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a wrist-hand-finger orthosis (L3809) provided on November 15, 2019, by an OON provider.
You asked the Plan to pay for a wrist-hand-finger orthosis. You say that the requested item was necessary care for the enrollee. The Plan denied your request. The Plan says rules for OON care have not been met.
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 a wrist-hand-finger orthosis (L3809) provided on November 15, 2019, by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve methylphenidate HCl tablet, 10 mg.

You asked the Plan to pre-approve the methylphenidate. You say that this medication is medically necessary. The Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not covered under 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 methylphenidate HCl tablet, 10 mg.

Benefits for the methylphenidate 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (CPT G0483) provided to the enrollee on June 11, 2020
.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained.

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 HCPCS code G0483 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's office (POS 11). 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 drug testing services (CPT G0483) provided to the enrollee on June 11, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pre-approve bronchoscopy.
You asked the Plan to pre-approve bronchoscopy. You say that the services are necessary. The Plan denied
your request. The Plan says that medical necessity has not been established. Therefore, coverage criteria have
not been met.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it is medically necessary.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve bronchoscopy. Our reviewer says that
the requested items/services are considered medically reasonable and necessary in this case. Our physician
reviewer found in this case the location and size of the nodule, and the enrollee's previous lung resection, make
it important to localize the lesion as accurately as possible to assist in the resection.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of bronchoscopy have been met. Therefore, we decided that the Plan has to preapprove
bronchoscopy.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a resection (30140) provided on October 15, 2020.

You asked the Plan to pay for a resection. You say that this is documented in the records. The Plan denied your request. The Plan says this code is not supported.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 30140 is submucous resection inferior turbinate, partial or complete, any method. 

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 a resection. Our reviewer says that this procedure cannot be verified. Our physician reviewer found the medical records provided do not include sufficient documentation to validate a submucous resection inferior turbinate, partial or complete, any method was performed on October 15, 2020. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a resection have not been met. Therefore, we decided that the Plan does not have to pay for a resection (30140) provided on October 15, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion device.

You asked the Plan to pre-approve a Vertiflex Superion device. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

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 a Vertiflex Superion device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device remains experimental. More research is needed to show safety and efficacy of the device. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Vertiflex Superion device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Superion device.