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

We decided that the Plan does not have to waive the copayment forthe podiatry care provided on May 4, 2020.You asked the Plan to waive the copayment forthe podiatry care. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request.The Plan denied your request. The Plan says you received podiatry services on the date of service at issue in this appeal. The Plan says that the correct copayment hasapplied per your contract with the Plan.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 $45 copayment for Podiatry Services. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received podiatry care on May 4, 2020. You have been asked to pay a $45 copayment for the podiatry care. The podiatry care falls within the Podiatry 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 forthe podiatry care provided on May 4, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe unspecified adjunctive service (D9999).You asked the Plan to pre-approvethe unspecified adjunctive service. You say that the enrollee's entire mouth has decay. You also say that the enrollee needs surgical extractions and an alveoloplasty prior to starting cancer treatment.The Plan denied your request. The Plan says the unspecified adjunctive procedure is not listed as a covered service.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 service is not among those covered under this benefit. The record shows that the unspecified adjunctive procedure is a "placeholder for ancillary service." The Customer Handbook clearly states if a dental item or service is not listed in the benefit chart then it is not covered.Therefore, we decided that the Plan does not have to pre-approvethe unspecified adjunctive service (D9999).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the $50 copayment for ambulance transport provided on July 26, 2020.
You asked the Plan to waive this transport. You say that you do not believe this copayment is correct. You say that you were told there would be no copayment. The Plan denied your request. The Plan says this copayment was charged based on the Plan contract agreement and the services 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 $50 copayment for ambulance transport. 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 $50 copayment for ambulance transport provided on July 26, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for arthroscopy services provided to the enrollee on May 27, 2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the records provided do not support the services 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. 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 this service. Our reviewer says that Medicare billing criteria are not met. Our physician reviewer found the medical records provided do not include sufficient documentation to validate that an Arthroscopy, shoulder, surgical; debridement, extensive was performed on the right shoulder. Therefore, this service cannot be verified. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for arthroscopy services provided to the enrollee on May 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvefoot orthotics (L3020 x 2) and range of motion measurements (95851x 2).You asked the Plan to pre-approvethese items and services. You say that you are requesting a reconsideration of the Plan's denialas the foot orthotics are medically necessary.The Plan denied your request. The Plan says these items and services 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-approvefoot orthotics (L3020 x 2) and range of motion measurements (95851 x 2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea removal of an impacted tooth (D7230).You asked the Plan to pre-approvethe removal of an impacted tooth. The Plan denied your request. The Plan says this service is not covered under your benefit package.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-approvea removal of an impacted tooth (D7230).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approved seat lift mechanism (E0627).

You asked the Plan to pre-approve this item. You say that a seat lift mechanism is medically necessary.The Plan denied your request. The Plan says you do not meet Medicare criteria for coverage of a seat lift mechanism.

The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed above are met.

We looked at the case file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this item have not been met.Specifically, the medical records provided do not indicate that you have severe arthritis of the hip or knee or have a severe neuromuscular disease. Additionally, the record does not indicate that you are completely incapable of standing from a chair in your home.Therefore, we decided that the Plan does not have to pre-approvea seat lift mechanism (E0627).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe outpatient surgical procedure provided on July 16, 2020.You asked the Plan to waive the copayment forthe outpatient surgical procedure. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request.The Plan denied your request. The Plan says you received an outpatient surgical procedure in an outpatient hospital setting on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.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 $400 copayment for Outpatient surgery.We looked at the file, the Plan's contract and Medicare rules. The file shows that you received an outpatient surgical procedure on July 16, 2020. You have been asked to pay a $37.44 copayment for the outpatient surgical procedure, which is less than the $400 contracted copayment amount. The outpatient surgical procedure falls within the Outpatient surgery 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 forthe outpatient surgical procedure provided on July 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecustom abutments (D16057) for teeth # 12, 21 and 29.You asked the Plan to pre-approvethe dental services. You say that you cannot eat. You say that you can hear your teeth cracking. You also say that you are willing to pay if possible.The Plan denied your request. The Plan says custom abutment is not listed as a covered service.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-approvecustom abutments (D16057) for teeth # 12, 21 and 29.
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 March 27, 2020.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, wedecided that the Plan does not have to pay fora knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on March 27, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe surgical extraction (D7210) and a consultation (D9310) to be provided by an oral surgeon.You asked the Plan to pre-approvethe dental services. You say that your dentist advised that they are unable to perform a surgical extraction. You say that your tooth is broken below your gum. You say that you are in pain. You also say that it is effecting your ability to eat since it is a front tooth.The Plan denied your request. The Plan says services must be performed by a participating general dentist to be covered. The Plan also says that services provided by an oral surgeon are notcovered.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 services that you receive from an oral surgeon are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvethe surgical extraction (D7210) and a consultation (D9310) to be provided by an oral surgeon
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the consultation and extraction of erupted tooth (D7210, D9310).
You asked the Plan to pre-approve the consultation and extraction of erupted tooth. You say that these services are medically necessary for your condition. The Plan denied your request. The Plan says although they offer supplemental dental services beyond what Medicare covers, the contract only covers dental services when performed by a participating general dentist.
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 because they will not be performed by a participating general dentist. Therefore, we decided that the Plan does not have to pre-approve the consultation and extraction of erupted tooth (D7210, D9310).
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for3D rendering with interpretation and reporting of modality with image postprocessing (76377-26) provided June 2, 2020.You asked the Plan to pay forcode 76377. You say that the medical records support the services billed.The Plan denied your request. The Plan says that reimbursement for 3-D rendering is considered part of the primary procedure.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 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 code 76377. Our reviewers says that medical records support the billing of code 76377. Our physician reviewer found code 70553 is 2D magnetic resonance imaging (MRI), and code 76377 is 3D rendering and interpretation. Code 76377 must be reported with the base imaging procedure.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rulesfor coverage of code 76377 have been met. Therefore, we decided that the Plan has to pay for3D rendering with interpretation and reporting of modality with image postprocessing (76377-26) provided June 2, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transports.
You asked the Plan to pre-approve these services. You say that you need additional trips to your appointments. The Plan denied your request. The Plan says you have exhausted the benefit limit.
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. The Plan covers a maximum of 60 one-way trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transports.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approvea panniculectomy.You asked the Plan to pre-approvethese services. You say that you have continuous back problems.The Plandenied your request. The Plan says that the services are not medically necessary.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 these services. Our reviewer says that the services are medically necessary. Our physician reviewer found the submitted records show that you have a symptomatic lower abdominal pannus. You have chronic rashes related to the pannus that have been treated by your primary care physician and with antifungal medication. You have been treated since December 19, 2019 and it has failed to be resolved. There is evidence of picking at the skin (excoriation) under the pannus, which supports clinical functional impairment. You also have chronic back pain that may be related to the pannus. You have evidence of functional impairment due to the overlapping lower abdominal pannus that has failed typical conservative management. The panniculectomy is therefore reasonable and medically necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have been met.Therefore, we decided that the Plan has to pre-approvea panniculectomy.If the Plandoes 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 doesnot happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services provided and billed with code 99152.

You asked the Plan to pay for the moderate sedation services. You say that this should be paid.The Plan denied your request. The Plan says the code 99152 is not supported in the operative report.

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 99152 is Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intra-service time, patient age 5 years or older.

We find that CPT code 99152 is not supported in the medical record. Specifically, there is no specific documentation of the presence of a trained independent observer. Based on this information, we decided that Medicare rules for coverage of the moderate sedation services have not been met.Therefore, we decided that the Plan does not have to pay for the moderate sedation services provided and billed with code 99152
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea spinal bone growth stimulator.You asked the Plan to pre-approvethese services. You say that the surgery is needed for you to move forward with your life.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that a bone growth stimulator is covered when specific criteria are met.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 services are not medically necessary. Our physician reviewer found the submitted records show that you have severe narrowing of the neck spine (cervical spinal stenosis). Magnetic resonance imaging (MRI) of the neck spine showed cord compression. You are planned for surgery. You have no history of failed spinal fusions and the planned surgery is only at one level. You do not meet the criteria for coverage of the requested bone growth stimulator. The services are not reasonable or medically necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pre-approvea spinal bone growth stimulator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse for the limited oral evaluation and the biopsy for the roof of mouth provided from January 28, 2020, to March 4, 2020.
You asked the Plan to reimburse for the dental services. You say that these procedures were done by the only oral surgeon in your vicinity. You say that you paid for the services at the time of your appointments as you thought you would be reimbursed. The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan also says that payment cannot be made for services that you receive from a provider who has opted out of Medicare.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to reimburse for the limited oral evaluation and the biopsy for the roof of mouth provided from January 28, 2020, to March 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fordurable medical equipment provided to the enrollee on July 8, 2020.You asked the Plan to pay forthis claim. You say that this equipment should be paid by the Plan.The Plan denied your request. The Plan says the code E0745 was not billed with the required durable medical equipment modifier. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes and when necessary the appropriate modifiers. In this case, this claim cannot be paid as billed due to a modifier issue. Medicare rules for coverage of this claim have not been met.Therefore, we decided that the Plan does not have to pay fordurable medical equipment provided to the enrollee on July 8, 2020.