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

We decided that the Plan does not have to pay for a pneumatic compression device (E0673, E0675) provided to the enrollee on April 6, 2021.
You asked the Plan to pay for the device. You say that there are studies that show this device is not experimental and investigational, and rather an industry standard. The Plan denied your request. The Plan says devices coded with E0675 are not considered to be reasonable or necessary.
The Plan must follow Medicare rules. Medicare rules say that a pneumatic compression device coded with E0675 is used in the treatment of peripheral arterial disease, and will be denied as not reasonable and necessary. If the base device is not covered, then the related accessories will also not be 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 pay for the device. Our reviewer says that Our physician reviewer found 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 pay for a pneumatic compression device (E0673, E0675) provided to the enrollee on April 6, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tepezza injection services.
You asked the Plan to pre-approve the Tepezza. You say that you would like reconsideration because the records provided support the need for the requested drug. The Plan denied your request. The Plan says the requested drug does not meet medical necessity criteria for coverage.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Tepezza. Our reviewer says that the record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. Our physician reviewer found the record indicates that thyroid function tests were ordered as well as an endocrinology consult but no results were provided. 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 Tepezza have not been met. Therefore, we decided that the Plan does not have to pre-approve Tepezza injection services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay you directly for out-of-network mental health care services you 
received from February 11, 2021, to May 27, 2021. 
 
You asked the Plan to pay you directly for the out-of-network mental health care services. You say that you 
have been waiting for reimbursement on these claims for months and you would like to be paid. The Plan 
denied your request. The Plan says these claims were processed correctly, assessing you 30% coinsurance. 
 
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 30% 
coinsurance for out-of-network mental health services.  
 
You have been asked to pay 30% coinsurance for the out-of-network mental health care services. This means 
the cost sharing was correctly calculated 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 pay you directly for out-of-network mental health care services you received from February 11, 2021, to 
May 27, 2021.  
 
Your complaint about direct reimbursement is not a valid appeal for medical coverage. It appears as though 
you may have paid these claims up front and that your Plan paid the claims directly to the provider.  We do not 
have jurisdiction to review issues of how payment is made. 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 compression stockings identified with code A6533. 
 
You asked the Plan to pre-approve the compression stockings. You say that this equipment is medically 
reasonable and necessary. The Plan denied your request. The Plan says this specific item is statutorily non-
covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6533.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the diagnostic mammography coded 77065 provided on December 10, 2020.
You asked the Plan to pay for the diagnostic mammography. 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 code77065 for the diagnostic mammography is a column II code to column I code 77066. 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 diagnostic mammography coded 77065 provided on December 10, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Vitamin D screening (82306) provided on May 7, 2021.
You asked the Plan to pay for the Vitamin D screening. You say that you would like reconsideration because this testing was medically necessary. The Plan denied your request. The Plan says preventative vitamin assays and metabolic function tests 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. 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 Vitamin D screening. Our reviewer says that the review has determined that the testing was ordered for routine screening. Our physician reviewer found the testing was not reasonable and necessary for the diagnosis or treatment of an illness. We looked at this physician's review, the file and Medicare rules. Based on this information we determined that Medicare criteria for coverage of the Vitamin D screening have not been met. Therefore, we decided that the Plan does not have to pay for the Vitamin D screening (82306) provided on May 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power operated vehicle (K0800).
You asked the Plan to pre-approve a power operated vehicle. You say that this equipment is medically reasonable and necessary. The Plan denied your request. The Plan says the coverage criteria have not been met.
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. The file shows that there is no evidence your condition cannot be improved by a walker, cane or manual wheelchair. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a power operated vehicle (K0800).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided from May 17, 2021, to 
May 22, 2021. 
 
You asked the Plan to pay for the self-administered drugs. You say that you cannot afford to pay for this bill 
which is why you have insurance. The Plan denied your request. The Plan says self-administered drugs are not 
Part B covered. 
 
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 pay for the self-administered drugs 
provided from May 17, 2021, to May 22, 2021.  
 
Benefits for the self-administered drugs 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the placement of a septal strap (30999) provided on
May 17, 2021.
You asked the Plan to pay for the placement of a septal strap. You say that you would like reconsideration because this procedure was medically necessary. The Plan denied your request. The Plan says reimbursement for the NG tube and septal strap placement for anchoring the tube is bundled into the DRG for the member's hospitalization.
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 30999 is unlisted procedure, nose.
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 placement of a septal strap. Our reviewer says that CPT code 30999 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records submitted indicate that a feeding tube was placed, therefore it is inappropriate to submit CPT 30999 to represent placement of a septal strap to keep the nasogastric (NG) tube in place, as this service would be included in the payment of the Diagnosis Related Grouping (DRG) for hospitalization and no additional reimbursement is allowed. 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 placement of a septal strap have not been met. Therefore, we decided that the Plan does not have to pay for the placement of a septal strap (30999) provided on May 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), panoramic x-rays (D0330) and prophylaxis (D1110) provided on July 19, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for a comprehensive oral evaluation, panoramic x-rays, and prophylaxis. You say that you have always been seen by an OON provider and you were unaware they would deny this time. You also say your initial dentist passed away and you don't have a lot of dentists in your area. The Plan denied your request. The Plan says services provided by an OON or non-contracted provider 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. The Plan covers a comprehensive oral evaluation, panoramic x-rays, and prophylaxis when the services are provided by a participating provider.
We looked at the file and Medicare rules. The EOC confirms that you must receive services from a participating dental provider. Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral evaluation, panoramic x-rays and prophylaxis have not been met. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), panoramic x-rays (D0330) and prophylaxis (D1110) provided on July 19, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair.
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied your request. The Plan says only items that are medically necessary can be approved.
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 the documentation does not support that you have a mobility limitation that significantly impairs her ability to participate in one or more mobility-related activities of daily living such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home.
The documentation does not reveal that your mobility limitation cannot be sufficiently and safely resolved by the use of an appropriately fitted cane or walker or manual wheelchair. The documentation does not reveal that the use of the power wheelchair will significantly improve your mobility-related activities of daily living in the home. 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 power wheelchair.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found you do not require skilled therapy to establish 
a safe and effective maintenance program. As a practical matter, you do not require any skilled services on an 
inpatient basis, at a SNF level of care at the time of discharge from the hospital. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital stays provided from June 5, 2020, to June 13, 2020.
You asked the Plan to waive the copayment for inpatient hospital stays. You say that that you had no choice in what kind of room you received and disagree with the charges. You state that for the second stay you were only there one day and should not owe anything. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $195 copayment for days 1-7 for inpatient hospital care. The medical records show that you had an inpatient hospital stay from June 5, 2020, to June 9, 2020. Therefore, you are responsible to pay a $195 copayment for days 1-4 (June 5, 2020, to June 8, 2020). The total amount you owe for this stay is: $195 (copayment) x 4 (inpatient days) = $780.
The medical records show that you had an inpatient hospital stay from June 12, 2020, to June 13, 2020. Therefore, you are responsible to pay a $195 copayment for day 1 (June 12, 2020). The total amount you owe for this stay is: $195. The total amount you owe is: $975. You have been asked to pay the total copayment amount of $975 for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital 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 inpatient hospital stays provided from June 5, 2020, to June 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on  
July 26, 2021.  
You asked the Plan to pay for the dental service. You say that the additional exam was due to pain that you 
were experiencing after a root canal. 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. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of the dental service have not been met. Specifically, the frequency limit has been exceeded. The 
record shows that the Plan paid for a limited oral evaluation that you received on June 9, 2021. Therefore, we 
decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on July 26, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hymovis (J7322). 
 
You asked the Plan to pre-approve Hymovis. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says this medication is not covered when knee arthroplasty (replacement) is 
being considered. 
 
The Plan must follow Medicare rules. Medicare rules say that coverage of viscosupplementation therapy of the 
knee assumes that knee arthroplasty is not being considered as a current treatment option. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Hymovis have not been met. Specifically, the file indicates you are considering a knee replacement 
but are waiting on clearance from the enrollee's cardiologist. Therefore, we decided that the Plan does not have 
to pre-approve Hymovis (J7322).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive periodontal evaluation (D0180) provided on June 25, 2021.
You asked the Plan to pay for a comprehensive periodontal evaluation. You say that you were referred to the periodontist for an overall periodontal examination to maintain your teeth and gum health. You also say the examination was required. The Plan denied your request. The Plan says there is a list of approved dental benefits and covered codes and the above services received are not on that list.
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 EOC confirms a comprehensive periodontal evaluation is not a covered benefit with Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for a comprehensive periodontal evaluation (D0180) provided on June 25, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (J1170, J0735) provided on March 3, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes are not 
supported. 
 
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 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 use of codes J1170 
and J0735 is not supported by the records provided. Our reviewer found that the documentation supports 
compounding medications for infusion pump, and no single injections were given to support J1170 and J0735.  
Therefore, these HCPCS codes cannot be confirmed as performed. 
 
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 the services (J1170, J0735) provided on March 3, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the intracept procedure (CPT code(s): C9752, C9753, 22899)
You asked the Plan to pre-approve the intracept procedure. You say that given the enrollee's history, physical examination, the debilitating nature of their axial pain and radiologic findings, the intracept procedure is medically necessary for the enrollee. The Plan denied your request. The Plan says the clinical value and effectiveness of the intracept procedure in the setting of low back pain have not been demonstrated in the peer-reviewed literature.
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 intracept procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the intracept procedure is experimental. More research is needed to show safety and efficacy for low back pain.
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 intracept procedure have not been met.
Therefore, we decided that the Plan does not have to pre-approve the intracept procedure (CPT code(s): C9752, C9753, 22899).