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

 We decided that the Plan does not have to pre-approve a new microprocessor controlled ankle foot system.  You asked the Plan to pre-approve a new microprocessor controlled ankle foot system. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested item is not medically necessary.  The Plan follows Medicare rules. Medicare rules say that prostheses are only covered for certain indications.  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 new microprocessor controlled ankle foot system. Our reviewer says that the documentation does not support that the requested item is medically reasonable or necessary. Our physician reviewer found there is no documentation that you have a diagnosis/condition that meets criteria for the requested new microprocessor controlled ankle foot system. Records indicate that you have a mechanical K3 ankle foot system that is less than one year old and still under warranty with no documentation that it is irreparably damaged or that you have had a physiologic change requiring a new prosthesis. Therefore, you do not meet criteria for the requested item.  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 new microprocessor controlled ankle foot system have not been met. Therefore, we decided that the Plan does not have to pre-approve a new microprocessor controlled ankle foot system.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the X-ray of knee (73564) provided on August 2, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the X-ray of knee. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered by an OON provider.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the X-ray of knee (73564) provided on August 2, 2021, by an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ambulance service, advanced life support, emergency transport (A0427), and ground mileage (A0425) provided on March 22, 2021.  You asked the Plan to pay for the ambulance services. You say that the enrollee was not on hospice at the time of transport. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.  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 date of service at issue in this appeal. The hospice benefit begins the date of the election and is not time specific. Therefore, we decided that the Plan does not have to pay for the ambulance service, advanced life support, emergency transport (A0427), and ground mileage (A0425) provided on March 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the two dimensional (2D) oral/facial photographic image (D0350), adjunctive pre-diagnostic test (D0431), and oral hygiene instructions (D1330) provided on November 10, 2020.  

You asked the Plan to pay for the 2D oral/facial photographic image, adjunctive pre-diagnostic test, and oral hygiene instructions. You say that you would like to appeal these services. The Plan denied your request. The Plan says these services are not covered under your 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 two dimensional (2D) oral/facial photographic image (D0350), adjunctive pre-diagnostic test (D0431), and oral hygiene instructions (D1330) provided on November 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for hospital care (99232) provided from January 23, 2021, to February 7, 2021.  You asked the Plan to pay for hospital care. You say that this should be covered. The Plan denied your request. The Plan says there are no records to support this service.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  We find that CPT code 99232 is not supported in the medical record. Specifically, no records documenting these services have been submitted. Without this information, this code cannot be verified. Based on this information, we decided that Medicare rules for coverage of hospital care have not been met. Therefore, we decided that the Plan does not have to pay for hospital care (99232) provided from January 23, 2021, to February 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for a CTP procedure (0042T) provided on June 10, 2021.  

You asked the Plan to pay for a CTP procedure. You say that the services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for the services at issue have 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 pay for a CTP procedure. Our reviewer says that the services at issue are not considered medically reasonable and necessary in this case. Our physician reviewer found that the record submitted is insufficient to determine whether the elements of the coverage criteria are satisfied.  

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 CTP procedure have not been met. Therefore, we decided that the Plan does not have to pay for a CTP procedure (0042T) provided on June 10, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an MRI provided on July 24, 2021.  You asked the Plan to waive the copayment for an MRI. You say that you cannot afford 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 $325 copayment for diagnostic radiology services.   You have been asked to pay a $325 copayment for an MRI. An MRI falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an MRI provided on July 24, 2021.
Appeal type: Imaging
Decision: Favorable

 We decided that the Plan has to pay for the electrocardiogram provided on December 3, 2020.  You asked the Plan to pay for the electrocardiogram. You say that the service was medically necessary. The Plan denied your request. The Plan says that no prior authorization was obtained.  The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.  The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not submit the complete Evidence of Coverage. This means we cannot determine if the Plan's denial of non-emergent services is supported. Therefore, we decided that the Plan has to pay for the electrocardiogram provided on December 3, 2020.   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 to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the complete maxillary denture (D5110) and complete mandibular denture (D5120) provided on August 18, 2021.  

You asked the Plan to pay for the complete dentures. You say that you expected for your copayment to be $150.00 in total for both complete upper and lower dentures. The Plan denied your request. The Plan says the copayments applied toward the complete upper denture and complete lower denture are correct. 

 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, you are responsible for a $150 copayment for each complete denture. Therefore, we decided that the Plan does not have to pay for the complete maxillary denture (D5110) and complete mandibular denture (D5120) provided on August 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory testing provided on July 30, 2021.  You asked the Plan to pay for lab tests. You say that you have no knowledge of patient coverage prior to the specimen's arrival at your laboratory. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because the documentation submitted does not support the Place of Service (POS) code billed on this claim.  The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS).   We looked at the file and Medicare rules. The documentation shows that the sample for this testing was taken in an assisted living facility setting, therefore the POS code 81 - indicating an independent lab setting - is not appropriate for this claim. Based on this information, we decided that Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on July 30, 2021.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to pay for the x-rays coded 73610 and 73630 and the emergency department visit coded 99283 provided on June 13, 2021.  You asked the Plan to pay for the x-rays coded 73610 and 73630 and the emergency department visit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  We find that CPT codes 73610, 73630, and 99283 are not supported in the medical record. Specifically, codes 73610 and 73630 have a status indicator of Q1. This means that these services are packaged under Outpatient Prospective Payment System (OPPS) and separate payment cannot be made for these codes.   The outpatient code editor indicates that a medical visit on the same date of service as procedure 29515 (defined as application of short leg splint) without modifier 25 is not separately payable. Based on this information, we decided that Medicare rules for coverage of the x-rays coded 73610 and 73630 and the emergency department visit have not been met. Therefore, we decided that the Plan does not have to pay for the x-rays coded 73610 and 73630 and the emergency department visit coded 99283 provided on June 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve F2 gene analysis.  You asked the Plan to pre-approve F2 gene analysis. You say that you do not agree that only pregnant women meet the criteria for the requested genetic testing. The Plan denied your request. The Plan says the requested testing is only covered or pregnant patients.  The Plan follows Medicare rules. Medicare rules say that genetic testing for F2 is considered investigational for all indications outside of pregnant women unless there are unusual circumstances where testing will change clinical management of the patient.   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 F2 gene analysis. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee has a family history of thrombosis in her mother and two maternal uncles. The enrollee was diagnosed with an unprovoked severe venous thrombotic event (pulmonary embolism with pulmonary infarct). The enrollee reported that she is very concerned why she developed the pulmonary embolism. There is no evidence of a malignancy based on a recent whole body computed tomography (CT) scan. The case file does not support that there are unusual circumstances where the requested testing will change the clinical management of the enrollee in this case.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of F2 gene analysis have not been met. Therefore, we decided that the Plan does not have to pre-approve F2 gene analysis.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the inpatient hospital admission and services provided from July 5, 2021, to July 7, 2021.  

You asked the Plan to waive the copayment for inpatient care. You say that you should not be responsible for this payment. The Plan denied your request. The Plan says this claim was processed correctly, and your copayment was assessed in accordance with your contract.  

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 $325 copayment for each of the first six days of an inpatient hospital stay.   

You have been asked to pay a $650 copayment a two-day inpatient hospital stay ($325 x 2 = $650). 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 inpatient hospital admission and services provided from July 5, 2021, to July 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a continuous glucose monitor and supplies provided on June 14, 2021.  You asked the Plan to pay for a continuous glucose monitor and supplies. You say that the Plan-contracted provider's ordering process is filled with delays and obstacles. The Plan denied your request. The Plan says the supplier of the items at issue is not enrolled in the Medicare program.  The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program.  Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for a continuous glucose monitor and supplies provided on June 14, 2021.   Your complaint about receiving erroneous or incomplete information about your benefits from a representative of the Plan 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: Supplemental Benefit
Decision: Favorable

 We decided that the Plan has to pre-approve scaling and root planing (D4341 x 4).  You asked the Plan to pre-approve the dental services. You say that the requested services are necessary. The Plan denied your request. The Plan says that the scaling and root planing for all 4 quadrants are not medically necessary.  The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.  The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. We find that the Plan requires x-rays to determine the necessity of scaling and root planing. There were no x-rays provided in the case file to substantiate the Plan's denial. Without x-rays, we cannot determine if the requested scaling and root planing for all 4 quadrants is necessary. Therefore, we decided that the Plan has to pre-approve scaling and root planing (D4341 x 4).   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 to open the case again, we will send you a letter.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the GeneSight Psychotropic testing provided on August 10, 2021.  You asked the Plan to pay for the testing services. You say that the testing should be approved and paid. The Plan denied your request. The Plan says the testing has not been shown to be useful and is not covered. The Plan must follow Medicare rules. Medicare rules say that pharmacogenomics testing is only covered under certain medical indications.   We looked at the file, and Medicare rules. In this case, there are insufficient medical records to show that the testing was ordered based on the enrollee's response to a medication. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the GeneSight Psychotropic testing provided on August 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the extraction (D7210) provided on August 18, 2021, by the out of network provider.  You asked the Plan to pay for the dental service. You say that you thought the extraction would be covered due to a dental emergency. The Plan denied your request. The Plan says the extraction is not listed as a covered service. The Plan also says that you did not purchase the option supplemental 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 extraction is not among those covered under this benefit. Additionally, the record shows that you were aware prior to receiving the service that the extraction would not be covered. Therefore, we decided that the Plan does not have to pay for the extraction (D7210) provided on August 18, 2021, by the out of network provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve physical therapy provided by a participating provider.  

You asked the Plan to pre-approve physical therapy. You say that you still need assistance while walking. The Plan denied your request. The Plan says enrollee states that the pain is arthritic in nature and the further physical therapy is not indicated to treat these symptoms.  

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.   

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 physical therapy. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found further skilled therapy at this point does not appear to be likely to achieve any significant improvement in the enrollee's symptoms or functional status. Further utilization of the home exercise program appears appropriate at this point.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of physical therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve physical therapy provided by a participating provider.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the surgery services provided on June 30, 2021.  

You asked the Plan to pay for the services provided. You say that these are separately billable expenses. The Plan denied your request. The Plan says the services were inclusive to another billed code.  

The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.     

We looked at the file and the rules. The medical records do not show that the service billed with the -59 modifier is a distinct procedural service. Specifically, the services were not reported with the most comprehensive ode that describes the services performed. Services that are integral to a more comprehensive procedure shall not be unbundled. 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 surgery services provided on June 30, 2021.