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

We decided that the Plan does not have to pay for a pneumatic compression device (E0675 and E0673).
You asked the Plan to pay for a pneumatic compression device. You say that the items are medically necessary.
The Plan denied your request. The Plan says the pneumatic compression device is not covered by Medicare to
prevent deep vein thrombosis during and/or following surgery.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement.
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan.
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to
pay for a pneumatic compression device (E0675 and E0673).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for Fundus Photography (92250) provided on
August 31, 2021.
You asked the Plan to reimburse you for Fundus Photography. You say that you needed the retinal imaging
because you have a neoplasm of the right choroid. The Plan denied your request. The Plan says Fundus
Photography is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say Fundus Photography is not covered for routine
screening.
We looked at the file and Medicare rules. Medicare says that Fundus Photography is not covered for routine
screening. Therefore, we decided that the Plan does not have to reimburse you for Fundus Photography (92250)
provided on August 31, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the bone marrow aspirate.
You asked the Plan to pre-approve the bone marrow aspirate. You say that you would like reconsideration because the requested procedure is medically necessary. The Plan denied your request. The Plan says the use of bone marrow aspirate for this procedure is not covered.
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 the bone marrow aspirate. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found bone marrow aspirate remains experimental and more research is needed to show its safety and efficacy.
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 bone marrow aspirate have not been met. Therefore, we decided that the
Plan does not have to pre-approve the bone marrow aspirate
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the oral evaluation (D0150), prophylaxis (D1110), complete series x-ray (D0210), filling (D2335), tobacco counseling (D1320), scaling and root planing (D4341 x 3), and local anesthesia (D9210) provided from January 8, 2021, to February 9, 2021, provided by the out of network dentist.
You asked the Plan to pay an additional amount for the dental services. You say that you disagree with the amount due. The Plan denied your request. The Plan says out of network providers may bill you for any amount greater than what the plan paid the provider, even for services listed as $0 copayment. The Plan also says that scaling and root planing, local anesthesia, and tobacco counseling are not listed as covered services.
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 oral evaluation, prophylaxis, filling and x-ray are covered services, out of network providers may bill you for any amount greater that what the Plan pays the provider, even for services listed as $0 copayment. Although scaling and root planing is covered under the optional supplemental rider, the record shows this was not effective until February 1, 2021. Additionally, local anesthesia, and tobacco counseling are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay an additional amount for the oral evaluation (D0150), prophylaxis (D1110), complete series x-ray (D0210), filling (D2335), tobacco counseling (D1320), scaling and root planing (D4341 x 3), and local anesthesia (D9210) provided from January 8, 2021, to February 9, 2021, provided by the out of network dentist.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the outpatient hospital services rendered on August 3, 2021.
You asked the Plan to waive the deductible for these services. You say that you don't understand why the plan didn't pay towards the cost. The Plan denied your request. The Plan says the deductible was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is $500 yearly deductible which applies to your covered medical services. The item or service you asked the Plan to waive the deductible for falls within the outpatient hospital benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $500 yearly deductible which applies to your covered medical services. This cost sharing is a contractual obligation that had not been met at the time these services were received on August 3, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the outpatient hospital services rendered on August 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a follow up ophthalmic visit (92134, G0463) provided on August 9, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for a follow up ophthalmic visit. You say that the patient was seen for a follow-up visit and that the patient was last seen in November of 2020. The Plan denied your request. The Plan says this provider is not a network provider with the Plan. The Plan also says that they have also determined these services are not urgent or emergent, nor were they approved in advance.
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 follow up ophthalmic visit (92134, G0463) provided on August 9, 2021 by an out-of-network (OON) provider
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care, for the enrollee.
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care, for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that you are completely dependent and unsafe at home. The Plan denied your request. The Plan says your records show that you do not need to be seen by a rehabilitation doctor at least three (3) times a week and you do not require an intensive rehabilitation team in order to receive appropriate rehabilitation services. The Plan states you can safely receive the services you need in other settings, for example: a skilled nursing facility, home with home health and home physical therapy, or home with outpatient therapy.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.
Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for revision of a total hip replacement and was discharged home where there is ongoing weakness. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6530 provided on June 14, 2021.
You asked the Plan to pre-approve compression stockings. You say that the items at issue were a medical necessity for you. The Plan denied your request. The Plan says the items at issue are not a covered benefit.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6530 provided on June 14, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the power seat elevation feature (E2300), provided on August 27, 2021.
You asked the Plan to pay for the power seat elevation feature. You say that the item is medically necessary. The Plan denied your request. The Plan says this is not a covered item.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pay for the power seat elevation feature (E2300), provided on August 27, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for portable x-ray services provided on June 17, 2021.
You asked the Plan to pay for the portable x-ray services. You say that the medical records provided support the code in dispute, as it was billed. The Plan denied your request. The Plan says the Medicare rules for payment have not been met.
The Plan must follow Medicare rules. Medicare rules say that Medicare rules say that POS code 31 is for patients who are in a Part A covered SNF stay.
Medicare rules also say that the technical component of portable x-ray services during the course of a
Medicare-covered stay in a SNF, are subject to consolidated billing and must be included on the SNF's Part A
bill for the enrollee's covered stay. Medicare rules say that POS code 32 should be used with the services for
beneficiaries in a noncovered stay.
We looked at the file and Medicare rules. The case file shows that you billed this claim with a POS code of 31,
for a covered SNF stay. If this were appropriately used, then the technical components of the portable x-ray
services would be included in the SNF payment and not separately payable. If the SNF stay is not covered, then
the POS code billed was not appropriate. Based on this information, we decided that Medicare rules for
coverage of the portable x-ray services billed with a POS code of 31 have not been met. Therefore, we decided
that the Plan does not have to pay for portable x-ray services provided on June 17, 2021
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an X-ray provided on August 12, 2021.
You asked the Plan to waive the copayment for an X-ray. You say that you disagree with the charges and feel that they should be included under a surgical procedure. 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 $25 copayment for X-rays. You have been asked to pay a $25 copayment for an X-ray. An X-ray 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 X-ray provided on August 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the resin-based composite (D2393) provided on July 26, 2021.
You asked the Plan to pay more for the resin-based composite. You say that you feel that neither you or the Plan should have to pay for this service. The Plan denied your request. The Plan says this claim was submitted correctly and processed per your plan benefits. The Plan also says that they are not required to waive the $64.81 cost share for the filling.
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 50% coinsurance for resin fillings. Therefore, we decided that the Plan does not have to pay more for the resin-based composite (D2393) provided on July 26, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab services provided on July 14, 2021.

You asked the Plan to waive the copayment for lab services. You say that you feel that you should not owe multiple copayments because the labs should have all been taken at the same time and not spread out. 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 $5 copayment for lab services. 

You have been asked to pay a $5 copayment for lab services. Lab services fall 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 lab services provided on July 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services coded 01230 provided on August 2,
2021.

You asked the Plan to pay for the anesthesia services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.

In this case, the CPT Code Manual definition of code 01230 is anesthesia for open procedures involving upper
two-thirds of femur; not otherwise specified.

We find that CPT code 01230 is not supported in the medical record. Specifically, this anesthesia code was
billed without an appropriate surgical procedure code. A surgical code that appropriately crosswalks to the
anesthesia services must be reported to support the anesthesia code. Based on this information, we decided that
Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided that the Plan
does not have to pay for the anesthesia services coded 01230 provided on August 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for continuous intraoperative neuromonitoring (G0453) provided on July 27, 2021.

You asked the Plan to pay for continuous intraoperative neuromonitoring. You say that this procedure was medically necessary. The Plan denied your request. The Plan says the denial of payment for this service is correct, because code G0453 is not covered for diagnosis codes E04.2 or E21.3.

The Plan must follow Medicare rules. Medicare rules say that code G0453 is only covered for certain diagnosis codes which do not include codes E04.2 or E21.3. 

We looked at the file and Medicare rules. This claim was not billed with a diagnosis code for which G0453 may be covered. Based on this information, we decided that Medicare rules for coverage of continuous intraoperative neuromonitoring have not been met. Therefore, we decided that the Plan does not have to pay for continuous intraoperative neuromonitoring (G0453) provided on July 27, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the adjacent tissue transfer (14040) provided on May 18, 2021.

You asked the Plan to pay for the adjacent tissue transfer. You say that the modifier used on unpaid codes are allowed and should be processed as such. The Plan denied your request. The Plan says this procedure is not eligible for an assistant at surgery.

The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current Procedural Terminology (CPT) code 14040. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid.

Based upon this information, we find that Medicare coverage criteria for the assistant surgeon services for the adjacent tissue transfer have not been met. Therefore, we decided that the Plan does not have to pay for the adjacent tissue transfer (14040) provided on May 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for hearing aids provided on May 19, 2021.

You asked the Plan to reimburse you for hearing aids. You say that you had no idea that you needed to use a provider contracted with the Plan's hearing aid provider and you have never heard of this provider. You say you are handicapped with your hearing, and the cost of these hearing aids is too much money for you and you would have never purchased them out of pocket if you did not believe that you could be reimbursed. The Plan denied your request. The Plan says there is no evidence that you are unable to see a provider within the hearing aid provider network or that seeing a provider within the hearing aid network would not meet your needs.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when provider by a provider in the Plan's hearing aid network.

We looked at the file and the Plan's rules. The file shows that the hearing aids were not provided by a provider in the Plan's hearing aid network. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to reimburse you for hearing aids provided on May 19, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on February 8, 2021.

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 testing is not covered.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. 

The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on February 8, 2021.