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

We decided that the Plan does not have to waive the copayment for ambulance services you received on
October 11, 2021.
You asked the Plan to waive the copayment for the ambulance services. You say that you were told that
Veterans' Affairs (VA) would pick up this cost. The Plan denied your request. The Plan says you were charged
this copayment 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 $265
copayment for ambulance services.
You have been asked to pay a $265 copayment for the ambulance 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 copayment for ambulance services you received on October 11, 2021.
Your complaint about the VA picking up the cost is not a valid appeal for medical coverage. This part of your
complaint is a grievance that must be answered by the VA directly. Medicare does not permit us to make a
decision about these types of complaints.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Budesonide caplet 3mg DR for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your
request. The Plan says the enrollee does not have pharmacy/drug benefits.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Budesonide caplet 3mg DR
for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on August 20, 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 services were not billed correctly.
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT
codes describing the component test results.
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the
laboratory services rendered on August 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the tetanus, diphtheria toxoids and acellular pertussis vaccine
(TDAP) vaccine provided on October 15, 2021.

You asked the Plan to pay for the TDAP vaccine. You say that you would like reconsideration because you do
not know why the payment for this vaccine has been denied. The Plan denied your request. The Plan says you
received this vaccine as a preventative measure.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the TDAP vaccine. The Plan follows the same rules. 

Records do not show that you have been injured or directly exposed to any illness related to the TDAP vaccine. Therefore, we decided that the Plan does not have to pay for the tetanus, diphtheria toxoids and acellular pertussis vaccine (TDAP) vaccine provided on October 15, 2021.

Benefits for the TDAP vaccine may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve behavioral health therapy visits to be provided by an
out-of-network (OON) provider.
You asked the Plan to pre-approve the behavioral health therapy visits. You say that the out-of-network
therapist is highly recommended. The Plan denied your request. The Plan says a list of in-network providers
was given to the enrollee that can provide the same service.
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
behavioral health therapy visits to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection services coded 62320 provided on October 18, 2021.

You asked the Plan to pay for the injection 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 62320 is injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance.

We find that CPT code 62320 is not supported in the medical record. Specifically, the documentation submitted to the Plan did not include medical documentation or medical records for the services rendered. This means that Medicare coverage criteria cannot be confirmed. Based on this information, we decided that Medicare rules for coverage of the injection services have not been met. Therefore, we decided that the Plan does not have to pay for the injection services coded 62320 provided on October 18, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on August 25, 2020.

You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, ultianalyte assay with algorithmic analysis, or proprietary laboratory analysis CPT code. 

We looked at the file and Medicare rules. In this case, the requested genetic testing was billed with multiple codes. Per Medicare rules, the testing should be reported with one unit of one CPT code.

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 the lab services provided on August 25, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the abdominal x-ray interpretation provided on September 13, 2021.

You asked the Plan to pay for the x-ray interpretation. You say that this was reported with the correct POS code and must be paid. The Plan denied your request. The Plan says the enrollee was inpatient at the time these services were rendered. As such, POS code 21 is required.

The Plan must follow Medicare rules. Medicare rules say that for registered hospital inpatients or outpatients, the corresponding POS code should be reported for all services regardless of where the encounter takes place. 

In this case, the services were reported with outpatient POS code 22. However, the Plan has provided documentation showing that the enrollee was admitted as inpatient on September 11, 2021. As such, the reported POS code is not correct. Therefore, we decided that the Plan does not have to pay for the abdominal x-ray interpretation provided on September 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple power
options.
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied
your request. The Plan says this is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.
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 wheelchair. Our reviewer says that
the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found based on the
medical records provided, there is no documentation that you meet Medicare criteria for the multiple power
options and additional accessories. The records do not document the need for bladder self-catherization,
presence of muscle spasticity or history or presence of pressure ulcers or high risk for pressure ulcers to justify
the tilt/recline feature. The documentation shows that you have 5/5 upper extremity strength, and are
independent with toileting thus indicating you have adequate strength and function to operate the wheelchair's
power options with their own switches. Thus the expandable controller, harness and electronic connection do
not meet coverage criteria.
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 wheelchair have not been met. Therefore, we decided that the Plan does not
have to pre-approve a group 3 power wheelchair with multiple power options.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a walk-in shower or bath.
You asked the Plan to pre-approve a walk-in shower or bath. You say that the requested item is a medical
necessity for you. The Plan denied your request. The Plan says rules for coverage for durable medical
equipment have not been met.
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 pre-approve a walk-in shower or bath.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xiidra 5% eye drops.
You asked the Plan to pre-approve Xiidra 5% eye drops. You say that the patient has severe dry eyes. The Plan denied your request. The Plan says Xiidra is a self-administered drug and is not covered for the enrollee's condition by Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Xiidra 5% eye drops.
Benefits for Xiidra 5% eye drops may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection services coded 62320 provided on October 4,
2021.

You asked the Plan to pay for the injection 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 62320 is injection(s), of diagnostic or therapeutic
substance(s) (e.g., anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic
substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical, or thoracic;
without imaging guidance.

We find that CPT code 62320 is not supported in the medical record. Specifically, the documentation did not
include medical documentation or medical records. Without this required information, coverage criteria cannot
be determined. Based on this information, we decided that Medicare rules for coverage of the injection services
have not been met. Therefore, we decided that the Plan does not have to pay for the injection services coded
62320 provided on October 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for surgery services provided on September 24,
2021.

You asked the Plan to waive the copayment for the surgery services. You say that you had the same procedure
done with another provider and the copayment was lower. The Plan denied your request. The Plan says the
provider billed for the services and the proper copayment 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 $160
copayment for Outpatient Hospital Surgery Services.

You have been asked to pay a $160 copayment for surgery services. The surgery services fall within the
Outpatient hospital 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 surgery
services provided on September 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve four pontics (D6240 x4) and six retainer crowns (D6750 x6) to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the pontics and retainer crowns. You say that these services are medically needed. The Plan denied your request. The Plan says services are only covered by your Health Plan for in-network dentists. The Plan also says that the records do not show that your dentist is in the Plan's provider network.

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 OON. Therefore, we decided that the Plan does not have to pre-approve four pontics (D6240 x4) and six retainer crowns (D6750 x6) to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140), periapical x-ray
(D0220), crown (D2752), and core build up (D2950) provided on February 25, 2021.
You asked the Plan to pay for the dental services. You say that you have been seeing this dentist for over 25
years. You say that this dentist refused to accept your policy. You also say that you should be reimbursed for
these services. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan
also says that services obtained from vendors outside of the network are not 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, dental services that you obtain out of
network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to
pay for the limited oral evaluation (D0140), periapical x-ray (D0220), crown (D2752), and core build up
(D2950) provided on February 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the incision and drainage of an abscess (10061) provided on
March 4, 2021.
You asked the Plan to pay for the incision and drainage of an abscess. You say that you would like
reconsideration based on the records submitted. The Plan denied your request. The Plan says and edit exists
between CPT code 10061 and 11043.
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 10061
is a column II code to column I code 11043. 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 incision and drainage of an abscess (10061) provided on
March 4, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Teriparatide for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the requested drug is intended for patient self-administration.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Teriparatide for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular screening services coded 81442 provided on May 24, 2021.
You asked the Plan to pay for the cardiovascular screening 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 a covered benefit.
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. Cardiovascular risk assessment panels are only covered for certain indications. While cardiovascular risk assessment panels are covered for certain indications, the file does not support that the enrollee met criteria for these services. Therefore, we decided that the Plan does not have to pay for the cardiovascular screening services coded 81442 provided on May 24, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (87841, 87640, 87651, 87653, 87798) provided December 3, 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 87841, 87640, 87651, 87653, & 87798 is not supported in the medical record. Specifically, the place of service listed on the claim form (81, lab) does not match the place of service detailed in the records (11, office). 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 (87841, 87640, 87651, 87653, 87798) provided December 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213) to be rendered by an out-of-network (OON) provider.

You asked the Plan to pre-approve the maxillary partial denture. You say that you want to go to this OON provider to have the work finished. The Plan denied your request. The Plan says services provided by an OON or non-contracted provider are not provided under your benefit program.

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 a maxillary partial denture (D5213) to be rendered by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit provided on
September 7, 2021.

You asked the Plan to waive the copayment for an emergency room visit. You say that you were admitted into
the hospital and should not pay a copayment. The Plan denied your request. The Plan says the provider billed
for emergency care and the proper copayment 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 $90
copayment for each Medicare-covered emergency room visit.

You have been asked to pay a $90 copayment for an emergency room visit. An emergency room visit falls
within the Emergency care 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 room visit provided on September 7, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that unproven and not medically necessary procedures are not covered by Medicare due to insufficient evidence of efficacy.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The Intracept procedure is experimental. More research is needed to show safety and efficacy. Our physician reviewer found that your condition does not meet criteria for these services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure.