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

We decided that the Plan does not have to pay for debridement (eg, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound, (eg, fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) surface area; first 20 sq cm or less (CPT code 97597) and debridement (eg, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound, (eg, fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) surface area; each additional 20 sq cm, or part thereof (CPT code 97598) provided to the enrollee on April 12, 2021.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says mutually exclusive procedures cannot reasonably be performed at the same anatomic site or same patient encounter.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Review of the file shows that CPT code(s): 97597 and 97598, are Column 2 codes in relation to CPT code(s) 11042 and 11045 which are Column 1 codes in relation to the other codes, but a modifier could be used, and there were no modifiers used to allow the edit to be bypassed. Therefore, we decided that the Plan does not have to pay for CPT code 97597 and CPT code 97598 provided to the enrollee on April 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.

You asked the Plan to pre-approve foot orthotics. You say that you feel these items are medically necessary.
The Plan denied your request. The Plan says this item is not a covered benefit.

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-approve foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to a tertiary-level pain management specialist. 
 
You asked the Plan to pre-approve these service. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the tertiary level of care is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these service. Our reviewer says that 
the tertiary level of care is not medically necessary. Our physician reviewer found the submitted records show 
that you have chronic pain with lumbar spinal stenosis and pain from malfunction of the peripheral nerves 
(polyneuropathy). The records do not support that the tertiary level of care is reasonable and medically 
necessary. The Plan has in-network, non-tertiary providers that can adequately provide your care. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a referral to a tertiary-level pain management specialist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the ophthalmological services: medical
examination and evaluation with initiation of diagnostic and treatment program; comprehensive, new patient
(92004) and fundus photography with interpretation and report (92250) provided May 10, 2021.
You asked the Plan to reduce the copayment for the eye exam with photos. You say that this should be an
annual eye exam with a $15 fee. The Plan denied your request. The Plan says the copayment applied correctly.
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
specialist office visit copayment when you receive services that address a medical condition during a routine
eye exam.
You have been asked to pay a $45 copayment for the eye exam with photos. The eye exam with photos falls
within the Vision care benefit category. The record includes medical records showing that a medical condition
was evaluated during your exam. 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 reduce the copayment for the ophthalmological
services: medical examination and evaluation with initiation of diagnostic and treatment program;
comprehensive, new patient (92004) and fundus photography with interpretation and report (92250) provided
May 10, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the end-stage renal disease (ESRD) laboratory services 
provided on March 1, 2021 to March 31, 2021. 
 
You asked the Plan to pay for the ESRD laboratory 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 payable. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the end-stage renal disease (ESRD) laboratory services provided on March 1, 2021 to March 31, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for mobile radiology services provided on March 14, 2021 by an out-of-network provider.
You asked the Plan to pay for mobile radiology services. You say that the services were medically necessary and requested by the facility. The Plan denied your request. The Plan says you did not request prior authorization.
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 services at issue in this appeal.
The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for mobile radiology services (Q0092, 73090, R0070) provided on March 14, 2021 by an out-of-network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance service, advanced life
support, emergency transport, level 1 (A0427) and ground mileage, per statute mile (A0425) provided April 26,
2021.

You asked the Plan to waive the copayment for the emergency ambulance services. You say that the enrollee
experienced pain and suffering in the hospital and should not be responsible for any related copayments. The
Plan denied your request. The Plan says the copayment was applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees
must pay a $150 copayment per one-way trip by ground ambulance.

The enrollee has been asked to pay a $150 copayment for the emergency ambulance transport. The emergency
ambulance transport falls within the Ambulance services benefit category. This means that the enrollee has
been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not
have to waive the copayment for the ambulance service, advanced life support, emergency transport, level 1
(A0427) and ground mileage, per statute mile (A0425) provided April 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for negative pressure wound therapy services
you received at an outpatient hospital facility from May 26, 2021, to June 18, 2021.
You asked the Plan to waive the copayments for the negative pressure wound therapy. You say that your
surgeon told you that the wound center shouldn't have been probing or packing the wound. You said that
because you didn't need to go to these appointments, you shouldn't have to pay the copayment. The Plan denied
your request. The Plan says you were charged these copayments correctly. The Plan says that because the
allowed amounts for each date of service are less than your copayment, you are responsible for the full 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 $200
copayment for outpatient hospital services. You have been asked to pay a $200 copayment for the negative pressure wound therapy. The negative pressure
wound therapy falls within the outpatient hospital services benefit category. These copayments apply
regardless of the reason for the services. 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 copayments for negative
pressure wound therapy services you received at an outpatient hospital facility from May 26, 2021, to June 18,
2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99215) provided on December 28, 2020 by an out-of-network (OON) provider.

You asked the Plan to pay for the outpatient office visit. You say that you would like this denial to be reconsidered. The Plan denied your request. The Plan says the service provided requires prior authorization. The Plan also says that a prior authorization was not obtained.

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 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 outpatient office visit (99215) provided on December 28, 2020 by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient services provided from December 8, 2020, through 
December 14, 2020, with the reported secondary diagnosis N17.0, acute kidney failure with tubular necrosis. 
 
You asked the Plan to pay for inpatient services provided from December 8, 2020, through December 14, 2020, 
with the reported secondary diagnosis N17.0, acute kidney failure with tubular necrosis. The Plan denied your 
request. The Plan says the records do not indicate ATN as this member had perioperative prerenal azotemia. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with the secondary diagnosis N17.0, acute kidney failure 
with tubular necrosis. 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 inpatient services provided 
from December 8, 2020, through December 14, 2020, with the reported secondary diagnosis N17.0, acute 
kidney failure with tubular necrosis. Our reviewer says that that the documentation does not support that the 
inpatient care is payable as billed. Our physician reviewer found the documentation does not support N17.0, 
Acute kidney failure with tubular necrosis (a kidney disorder involving damage to the tubule cells of the 
kidneys, which can lead to acute kidney failure. The tubules are tiny ducts in the kidneys that help filter the 
blood when it passes through the kidneys). A diagnosis of tubular necrosis consists of increased blood urea 
nitrogen and creatinine in the urine, and sodium and creatinine in blood. The documentation shows a slight 
increase in creatinine with a decline, which does not support the diagnosis of acute kidney failure with tubular 
necrosis.  Therefore, the correct DRG to report for the inpatient hospital admission is 236. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient services provided from December 8, 2020, through December 14, 2020, with the reported 
secondary diagnosis N17.0, acute kidney failure with tubular necrosis.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM).
You asked the Plan to pre-approve therapeutic CGM. You say that you feel that this is medically necessary.
The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for a therapeutic
CGM.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations,
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment
plan.
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent selfadjustment
of insulin dosage based on the blood glucose testing results, have had an in-person visit with their
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this
information, we decided that Medicare rules for coverage of therapeutic CGM have not been met. Therefore,
we decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341) for all 
four quadrants and a root canal (D3320) for tooth #29. 
 
You asked the Plan to pre-approve the dental services. You say that these services are necessary care for your 
teeth, and you cannot afford the cost without help. The Plan denied your request. The Plan says these services 
are not covered by your dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
periodontal scaling and root planing (D4341) for all four quadrants and a root canal (D3320) for tooth #29.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment with no transport
(A0998) provided on April 19, 2021.

You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you were
having severe chest pain and were not sure if it was due to your heart complications. You also say that due to
your condition and being unsure of what would happen, you believe this service should be covered. The Plan
denied your request. The Plan says ambulance services in cases of non-transport are not covered by Medicare.

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 April 19, 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 with no
transport (A0998) provided on April 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an occlusal adjustment (D9952) provided on June 4, 2021.
You asked the Plan to pay for an occlusal adjustment. You say that you want the Plan to pay for the service at issue. The Plan denied your request. The Plan says the service at issue is not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an occlusal adjustment (D9952) provided on June 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics (L3000) provided on July 29, 2021.
You asked the Plan to pay for foot orthotics. You say that you are a diabetic and need the requested item for pain in your feet due to neuropathy. The Plan denied your request. The Plan says this item is not a covered benefit.
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. Provided medical records do not show that you suffer from diabetic foot disease or that you 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 pay for foot orthotics (L3000) provided on July 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a powered upper extremity range of motion assist device for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says here is not enough medical proof that shows the safety and/or success of this device for right upper arm partial paralysis.

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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the records provided do not include medical records from the ordering physician that establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The prescribing physician stats he is unfamiliar with the device and will refer to another physician for assessment. The elements of the coverage criteria are not 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 the device have not been met. Therefore, we decided that the Plan does not have to pre-approve a powered upper extremity range of motion assist device for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the power seat elevation system (E2300) and phone holder (K0108).

You asked the Plan to pre-approve the power seat elevation system and phone holder. You say that these items are medically necessary. The Plan denied your request. The Plan says these items are non-covered.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The rules also say that a power set elevation feature is statutorily non-covered. 

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. The phone holder available to the general public and would be helpful even to those who are not sick or injured. It is primarily a convenience item. In addition, the power seat elevation system is statutorily non-covered. Therefore, we decided that the Plan does not have to pre-approve the power seat elevation system (E2300) and phone holder (K0108).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the simple extractions (D7140) and surgical extractions (D7210) provided on May 17, 2021.
You asked the Plan to pay for the extractions. You say that you would like this claim to be reconsidered for payment. The Plan denied your request. The Plan says these services are non-covered procedures.
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. These extractions were provided due to decay, and not for a Medicare-covered purpose. The extractions are not Medicare covered and the dental benefit does not pay for the facility charges. Therefore, we decided that the Plan does not have to pay for the simple extractions (D7140) and surgical extractions (D7210) provided on May 17, 2021.