Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the adjunctive pre-diagnostic test (D0431) provided on April 8, 2021.
You asked the Plan to pay for the adjunctive pre-diagnostic test. You say that you went to the Plan's website and found that this treating provider was in-network with your plan. The Plan denied your request. The Plan says this service is not covered. The Plan also says that they confirmed with the provider's office that the office went over the services with you.
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. The record shows that when you contacted the Plan you were advised that the treating provider is in-network with the Plan. You were also advised that the Plan is code specific and you were sent a copy of the benefits showing what the covered services are for your plan. Therefore, we decided that the Plan does not have to pay for the adjunctive pre-diagnostic test (D0431) provided on April 8, 2021. Your complaint about disappointment with the Plan is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the PureWick Female Catheter system (A4335).
You asked the Plan to pre-approve the PureWick Female Catheter system. You say that the item is medically
necessary. The Plan denied your request. The Plan says the requested item is a non-reusable hygienic item.
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 the PureWick Female Catheter
system (A4335).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home oxygen therapy.
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your request. The Plan says the primary care physician is requiring an evaluation by a pulmonologist.
The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify for oxygen solely based on blood gas studies obtained during sleep. To qualify for home oxygen, the patient must meet one of the following blood gas levels: 1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest; 2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during sleep for a patient who have hypoxia symptoms during sleep; 3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for patients who have hypoxia symptoms during exercise; 4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of dependent edema, pulmonary hypertension, or erythrocythemia. For patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90% on room air, there is a rebuttable presumption of non-coverage. 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 therapy. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found the medical records of the visit on 9/20/21 include pulse oximetry at rest on room air, which was normal at 96%. There is no measure of oxygenation which indicates a need for oxygen supplementation. 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 therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve home oxygen therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for injection services (J9303) provided to the enrollee on March
2, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says the submitted medical record did not include the amount of wastage.
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 J9303 is "Injection, panitumumab, 10 mg."
We asked our coder 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 the services. Our reviewer says that the services at issue in
this case were not supported by the medical records. Our reviewer found the medical records provided do not
include sufficient documentation to support the billed waste, therefore this service cannot be verified.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not
have to pay for injection services (J9303) provided to the enrollee on March 2, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aduhelm.
You asked the Plan to pre-approve Aduhelm. You say that this is medically necessary. The Plan denied your request. The Plan says the records do not indicate the enrollee has Alzheimer's.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Aduhelm. Our reviewer says that the requested use of Aduhelm is not supported. Our physician reviewer found the Food and Drug Administration has stated that Aducanumab-avwa is indicated for the treatment of Alzheimer's disease and that treatment should be initiated in patients with mild cognitive impairment or mild dementia stage of disease. The documentation does not support that the enrollee has a covered indication for Aduhelm (Aducanumab). The documentation does not support a diagnosis of mild cognitive impairment or mild dementia stage of Alzheimer's disease. The documentation and imaging suggest a mixed etiology for the enrollee's symptoms. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Aduhelm have not been met. Therefore, we decided that the Plan does not have to pre-approve Aduhelm.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the consultation (D9310), cone beam CT capture (D0367), 
two surgical extractions (D7210 x2), two bone replacement grafts for ridge preservation (D7953 x2), two 
placements of intra-socket biological dressings (D7922 x2), oral surgery procedure (D7999), deep 
sedation/general anesthesia (D9222 and D9223 x3), and therapeutic parenteral drugs (D9612) provided from 
August 31, 2020, to October 7, 2020. 
 
You asked the Plan to pay for the dental services. You say that you paid out of pocket for these services and 
would like to be reimbursed. The Plan denied your request. The Plan says the services rendered were not 
medical and considered dental in nature. The Plan also says that the services rendered are also not covered by 
Original Medicare. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. 

Therefore, we decided that the Plan does not have to pay for the consultation (D9310), cone beam CT capture 
(D0367), two surgical extractions (D7210 x2), two bone replacement grafts for ridge preservation (D7953 x2), 
two placements of intra-socket biological dressings (D7922 x2), oral surgery procedure (D7999), deep 
sedation/general anesthesia (D9222 and D9223 x3), and therapeutic parenteral drugs (D9612) provided from 
August 31, 2020, to October 7, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head or brain coded as 70450 provided May 13, 2021.
You asked the Plan to pay for the CT scan of the head or brain. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says this claim was not billed with an appropriate modifier as required by Medicare rules.
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 70450 has a bundled relationship with code 70496 and cannot be paid as billed. This code cannot be paid as a separate line item. 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 computed tomography (CT) scan of the head or brain coded as 70450 provided May 13, 2021.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pay for the therapeutic exercises provided on November 20, 2019.

You asked the Plan to pay for the therapeutic exercises. You say that the Plan is required to pay non-contracted providers at the preferred rate if the services are not available from preferred providers. You say that the in-network benefits should be honored, and the claim processed for payment. The Plan denied your request. The Plan says that an appropriate modifier was not billed with this code edit.

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 97110 is therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility.
 
We find that CPT code 97110 is supported in the medical record. Specifically, while CPT code 97110 has a bundled relationship with CPT code 92526, there is no indication in the record that CPT code 92526 has been paid. It is not appropriate to apply bundling rules when the column I code has not been paid. Based on this information, we decided that Medicare rules for coverage of the therapeutic exercises have been met. Therefore, we decided that the Plan has to pay for the therapeutic exercises provided on November 20, 2019.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve left and right heart catheterization for the enrollee.
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says that the records do not show that the symptoms have persisted but did not worsen following a twelve-week trial of treatment.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. 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 procedure. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee has known pulmonary hypertension and metabolic syndrome. The enrollee is having progressive dyspnea on exertion and feels exercise tolerance is worse. An echocardiogram demonstrated severe pulmonary hypertension. A previous exercise stress test demonstrated ischemic changes. The provided records support the medical necessity and reasonableness, as defined by Medicare rules, of the requested service for the enrollee's condition. The elements of the coverage criteria are satisfied. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the procedure have been met. Therefore, we decided that the Plan has to pre-approve left and right heart catheterization for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lightweight wheelchair (K0001) and sales tax (S9999), provided on January 22, 2021.
You asked the Plan to pay for the lightweight wheelchair. You say that the item should be covered. The Plan denied your request. The Plan says the wheelchair has rental requirement and sales tax is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that for Capped Rental Items, pay the fee schedule amounts on a monthly rental basis not to exceed a period of continuous use of 15 months. In the tenth month of rental, the beneficiary is given a purchase option. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lightweight wheelchair have not been met. Specifically, this item is a capped rental item. This
means that it must be rented for at least 10 months before Medicare will give a purchase option. The record does not show that this item was rented for 10 months before a purchase option was made. Therefore, we decided that the Plan does not have to pay for the lightweight wheelchair (K0001) and sales tax (S9999), provided on January 22, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox.
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 medically necessary.
The Plan must follow Medicare rules. Medicare rules say that Botox is covered for specific indications only.
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 services are not medically necessary. Our physician reviewer found the enrollee has severe gastroparesis.
The FDA has not stated that Botox is indicated for this diagnosis and it is not listed as a covered indication in
the Medicare criteria. The Botox is therefore not reasonable or medically necessary for the enrollee.
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 Botox.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a computed tomography (CT) scan of the head/brain (70450) provided on May 4, 2021.
You asked the Plan to pay for CT scan. You say that you are appealing with records to support this level of service. The Plan denied your request. The Plan says the denial of payment for this service is correct, because codes 70496 and 70450 have a procedure-to-procedure (TP) edit and an appropriate modifier was not billed with this code.
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 70450 has a bundled relationship with code 70496 and cannot be paid as billed. This code cannot be paid as a separate line item without an appropriate modifier, which was not billed on this calim. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for a computed tomography (CT) scan of the head/brain (70450) provided on May 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist services rendered on April 20, 2021.
You asked the Plan to waive the copayment for these services. You say that you didn't have an office visit. 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). Your contract with the Plan clearly says that you must pay a $35 copayment for medical care or surgery services in a specialty physician's office.
Review of the file shows that you had a specialist office visit on April 20, 2021. The records show that you were seen and received services on this date. You have been asked to pay a $35 copayment for these services. These services fall within the medical care or surgery services in a specialty physician's office 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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on March 9, 2021.
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you believe this service should be paid for because it was provided for a separate issue. The Plan denied your request. The Plan says this service does not meet the frequency requirements of the Plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, problem focused limited oral evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem focused limited oral evaluation (D0140) on February 23, 2021 and your problem focused limited oral
evaluation (D0140) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on March 9, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 81226, 81230, 81291 and 81479) provided to the enrollee on November 9, 2020.
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied your request. The Plan says they have tried to reach out to the ordering to verify if they wrote the order for genetic testing for the enrollee. The Plan states the multiple outreaches had been made however, none of the documents received yet.
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 the laboratory services. Our physician reviewer found the review indicates that there was no written order for the laboratory studies therefore the plan was unable to confirm the requirement of the genetic testing. Ordering diagnostic tests, all diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary, that is, the physician who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results in the management of the beneficiary's specific medical problem. The review has determined that the documentation does not support that CPT code 81266 meets criteria as discussed in L35698. The documentation does not support that CPT code(s): 81230, 81291 and 81479 meet coverage criteria as discussed in L34519. 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 laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services (CPT code(s): 81226, 81230, 81291 and 81479) provided to the enrollee on November 9, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an incision and removal of a foreign body (10120) performed on May 24, 2021.
You asked the Plan to waive the copayment for an incision and removal of a foreign body. You say that the copayment charged is unreasonable for the service at issue which was not a surgical procedure. The Plan denied your request. The Plan says the correct 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 $150 copayment for Medicare-covered outpatient hospital surgery services. You have been asked to pay a $150 copayment for an incision and removal of a foreign body. An incision and removal of a foreign body falls within the "Outpatient surgery, including 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 an incision and removal of a foreign body (10120) performed on May 24, 2021.