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

 We decided that the Plan does not have to pay for lab services (G0481) provided May 20, 2020.  You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed services.  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 G0481 is not supported in the medical record. Specifically, the place of serivce on the claim (81, lab) does not match the place of service detailed in the records (11, office setting). Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (G0481) provided May 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for transcutaneous electrical modulation pain reprocessing (e.g, scrambler therapy), each treatment session (includes placement of electrodes) (0278T) provided July 19, 2021 to July 30, 2021.  You asked the Plan to pay for Scrambler therapy. You say that you have included medical records for review. please reprocess this claim for additional benefits. The Plan denied your request. The Plan says scrambler therapy/Calmare therapy device is unproven and non-covered.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered.   We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Scrambler therapy have not been met. Therefore, we decided that the Plan does not have to pay for transcutaneous electrical modulation pain reprocessing (e.g, scrambler therapy), each treatment session (includes placement of electrodes) (0278T) provided July 19, 2021 to July 30, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an emergency ambulance provided on July 30, 2021.  You asked the Plan to waive the copayment for an emergency ambulance. You say that you were forced to ride in the ambulance and should not be forced to pay. The Plan denied your request. The Plan says the proper copayment was applied to the service.  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 $290 copayment for Emergency Ambulance per date of service regardless of the number of trips. The total amount allowed was $259.48 which is less than the copayment amount of $290. Therefore, a copayment of $259.48 was billed.    You have been asked to pay a $259.48 copayment for an emergency ambulance. An emergency ambulance falls within the Ambulance services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an emergency ambulance provided on July 30, 2021.   Your complaint about your experience with this provider 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: Unfavorable

 We decided that the Plan does not have to pay for an unspecified preventative procedure (D1999), and a post-surgical complication treatment (D9930) provided by a participating provider on October 4, 2021.  You asked the Plan to pay for an unspecified preventative procedure and a post-surgical complication treatment. You say that you would like the Plan to pay for this. The Plan denied your request. The Plan says the services that were rendered are not covered dental benefits.  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 an unspecified preventative procedure (D1999), and a post-surgical complication treatment (D9930) provided by a participating provider on October 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an oxygen concentrator and portable oxygen concentrator.  You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says you have exhausted the 36 month rental benefit.  The Plan must follow Medicare rules. The rules say that reimbursement for oxygen equipment is limited to 36 monthly rental payments.   We looked at the file and Medicare rules. The file shows that you have used all 36 months of the covered rental for oxygen equipment. 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 an oxygen concentrator and portable oxygen concentrator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on September 15, 2021.  You asked the Plan to pay for the dental service. You say that this was an emergency visit for pain the tooth that need a root canal. You say that you cannot get an appointment until December 3, 2021. You also say that you feel this should be covered. The Plan denied your request. The Plan says 1 limited oral evaluation is covered per plan year. The Plan also says that the frequency limit has been exceeded.  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 and limited oral evaluation is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a limited oral evaluation that you received on February 22, 2021. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on September 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a partial upper denture (D5213) and a partial lower denture (D5214).  You asked the Plan to pre-approve partial dentures. You say that you lost your partials. You have that you have been biting your tongue. You say that you do not have molars. You also say that you have developed stomach issues from not being able to chew your food properly. The Plan denied your request. The Plan says partial dentures are covered once every 5 plan years. The Plan also says that the frequency limit has been reached.  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 and partial dentures are listed as covered, the frequency limit has been reached. The record shows that the Plan paid for partial dentures that you received on March 6, 2020. Therefore, we decided that the Plan does not have to pre-approve a partial upper denture (D5213) and a partial lower denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the resin-based composites (D2331 and D2332), crown (D2740), and core buildup, including any pins when required (D2950) provided on December 1, 2020 by a Medicare opt out provider.  You asked the Plan to pay for the resin-based composites, crown, and core buildup. You say that you have been using this dentist for years and services were paid for in 2019. You also say the coverage stated you did not have to use an in-network provider for services. The Plan denied your request. The Plan says you received these services from a provider who chose not to receive Medicare funds. The Plan also says that they confirmed with the provider's office that the practice informs their patients verbally that the provider had opted out of Medicare.  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 covered when they are received by a provider who has opted out of Medicare. Therefore, we decided that the Plan does not have to pay for the resin-based composites (D2331 and D2332), crown (D2740), and core buildup, including any pins when required (D2950) provided on December 1, 2020 by a Medicare opt out provider.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for sacroiliac fusion surgery performed on August 3, 2021.  You asked the Plan to waive the copayment for the fusion surgery. You say that you were not aware that the procedure was going to be at an outpatient hospital. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $90 copayment for outpatient procedures at an outpatient hospital.   You have been asked to pay a $90 copayment for the fusion surgery. The fusion surgery falls within the Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for sacroiliac fusion surgery performed on August 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the expandable controller and harness.  You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.  The Plan must follow Medicare rules. Medicare rules say that an expandable controller with harness are used to control multiple power options.  We looked at the file and Medicare rules. The file shows that the approved power wheelchair has a power recline and power elevating leg rests. Given that there are not three actuators, the expandable controller and harness are not needed. Therefore, we decided that the Plan does not have to pre-approve the expandable controller and harness.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a back brace.  You asked the Plan to pre-approve the requested item. The Plan denied your request. The Plan says there is no obligation to pay for a duplication of services.  The Plan must follow Medicare rules. The rules say if a DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary.  We looked at the file and the rules. The file shows that the enrollee has a back brace. His current brace serves the same purpose as the requested item. The records do not include an exam with the brace showing that it is no longer useful or has irreparable damage. Based on this information, the Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve a back brace.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve incontinence supplies.  You asked the Plan to pre-approve incontinence supplies. You say that the enrollee had a fall and is not able to transfer to the toilet with ease. The Plan denied your request. The Plan says the services are not covered.  The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable.   While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve repairs to a mobile shower chair.  You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.  The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature.   The requested services are repairs to a shower chair. Given that the shower chair is not covered by Medicare, the shower chair repairs are also not covered. Therefore, we decided that the Plan does not have to pre-approve repairs to a mobile shower chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an advanced foot/knee prosthetic.  You asked the Plan to pre-approve the requested items. You say that the enrollee wants his active life back. The Plan denied your request. The Plan says the records do not support the enrollee's functional status has advanced to K3.  The Plan follows Medicare rules. Medicare rules say that lower limb prostheses are only covered under certain medical 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 the requested items. Our physician reviewer found that a K3 prosthetic leg and vertical shock foot was requested. The physician documentation indicates the enrollee has physical debility as well as spondylosis of cervical region without myelopathy or radiculopathy, lumbar degenerative disc disease, left above the knee amputation, and is status post repair of hip fracture. The documentation does not support that the enrollee requires a heavier microprocessor knee given his multiple comorbidities. The documentation, indicating a need for a power wheelchair in addition to his prosthesis, does not support that the enrollee will be a K3 ambulator.  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 requested items have not been met. Therefore, we decided that the Plan does not have to pre-approve an advanced foot/knee prosthetic.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve 2 preventive dental visits with an out of network dentist.  You asked the Plan to pre-approve the dental services. You say that your previous dentist retired. You say that the requested provider is closer to your home. You also say that you do not drive much. The Plan denied your request. The Plan says dental services must be provided in network in order to be covered.  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 benefit exception for 2 preventive dental visits to be provided out of network are not among those covered under this benefit. The evidence of Coverage clearly states that services are only covered when received by a participating provider. Additionally, the Plan confirmed there are in network dentists available to provide these services. Therefore, we decided that the Plan does not have to pre-approve 2 preventive dental visits with an out of network dentist.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the rhythm electrocardiogram (ECG).  You asked the Plan to pay for the rhythm ECG. 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 separately payable.  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, we have confirmed that code 93042 is a column II code to column I code 93042. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the rhythm electrocardiogram (ECG).
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the insertion of stabilization device (22869 and 22870).  You asked the Plan to pre-approve the insertion of stabilization device (22869 and 22870). You say that the member has suffered from this condition for three years and has tried 6 months of conservative care without relief of symptoms. You say that this treatment is safe and effective and should be approved. The Plan denied your request. The Plan says neither Medicare nor the Plan cover this request.  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 insertion of stabilization device (22869 and 22870). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found interlaminar spacers remain experimental. More research is needed to show 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 insertion of stabilization device (22869 and 22870) have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of stabilization device (22869 and 22870).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the dietitian visit to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve the dietitian visit. You say that the service is medically necessary. The Plan denied your request. The Plan says the provider is out-of-network.  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 the dietitian visit to be provided by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ambulance response and treatment without transport (A0998) provided on June 17, 2021.  You asked the Plan to pay for ambulance response without transport. You say that you feel this claim was denied in error. The Plan denied your request. The Plan says the ambulance benefit is a transportation benefit. When no transportation is provided, there is no payable service.  The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport.   The ambulance company did not provide transport services on June 17, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment without transport (A0998) provided on June 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for radiology services (71045) provided August 24, 2021.  You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The Plan denied your request. The Plan says the code billed shares a bundled relationship with another code 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. In this case, we have confirmed that code 71045 is a column II code to column I code 71046. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for radiology services (71045) provided August 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for physician services (99153) provided July 1, 2021.  You asked the Plan to pay for the physician services. You say that the services were medically necessary. The Plan denied your request. The Plan says the billed code is not separately payable.  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 99153 is not supported in the medical record. Specifically, the code has a professional component / technical component indicator of 3 and was billed at place of service 22 (outpatient). In this setting payment is to the facility and this code is not separately payable per the National Physician Fee Schedule. Based on this information, we decided that Medicare rules for coverage of the physician services have not been met. Therefore, we decided that the Plan does not have to pay for physician services (99153) provided July 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for dialysis provided from August 4, 2021, to September 29, 2021.  You asked the Plan to waive the coinsurance for dialysis. You say that prior to switching contracts you never had to pay coinsurance and it should be waived. The Plan denied your request. The Plan says the proper coinsurance was applied.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for each dialysis center visit. The total amount billed was $3210 with a coinsurance of $642 ($3210 total amount x 20% coinsurance).    You have been asked to pay a 20% coinsurance for dialysis. Dialysis falls within the Renal (Kidney) dialysis 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 coinsurance for dialysis provided from August 4, 2021, to September 29, 2021.