Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy 60 minutes (90837) provided on March 24, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for psychotherapy services. You say that the enclosed medical records clearly reflect the medical necessity for the services rendered. The Plan denied your request. The Plan says there was no documented contact with the attending/primary care physician. The credentials of the provider do not qualify.
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 items/services at issue in this appeal. 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 psychotherapy 60 minutes (90837) provided on March 24, 2021 by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound represented by code 76700 provided on May 3, 2021.
You asked the Plan to pay for code 76700. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 76700 has a bundled relationship with code 93976 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 ultrasound represented by code 76700 provided on May 3, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for colonoscopy, flexible, proximal to splenic flexure (45385)
provided March 18, 2021.
You asked the Plan to pay for the diagnostic colonoscopy. You say that you are being charged for something
you were not aware that you was going to have to pay for. You should know what you are being charged for
under your insurance coverage. The Plan denied your request. The Plan says the claim was processed with the
correct cost share applied per the Evidence of Coverage.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that there is $750 deductible which applies to Outpatient hospital services. The item
or service you asked the Plan to pay for falls within the benefit category Outpatient hospital services. The Plan
has followed Medicare rules by clearly disclosing in the contract that there is $750 deductible which applies to
Outpatient hospital services. This is the amount you must pay out of pocket before the Plan will pay their share
of your medical services. This cost sharing is a contractual obligation that had not been met at the time the
diagnostic colonoscopy was received on March 18, 2021. Therefore, we decided that the Plan does not have to
pay for colonoscopy, flexible, proximal to splenic flexure (45385) provided March 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an arch support (L3010) provided on March 31, 2021.
You asked the Plan to pay for an arch support. You say that the item at issue should be covered as it is a preventive to surgery. 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 do not show that you do suffer from diabetic foot disease nor 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 an arch support (L3010) provided on March 31, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator (CPT code E0466-RR), for the enrollee.
You asked the Plan to pre-approve a home ventilator. You say that you are requesting review of denial of services. The Plan denied your request. The Plan says there is no documentation of hypercarbia (a blood test showing an increase in carbon dioxide levels), nor documentation of adequate trial and failure of bilevel positive airway pressure (BiPap), and therefore the appeal remains denied at this time.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 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 a home ventilator. Our physician reviewer found the Life2000 system is considered not medically necessary. This system is not a true ventilator, and efficacy data are insufficient in the treatment of COPD. A home ventilator is also considered not medically necessary. This enrollee has COPD, but an arterial blood gas shows no carbon dioxide (CO2) retention. The enrollee may benefit from treatment of the obstructive sleep apnea with CPAP. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator (CPT code E0466-RR), for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ambulance services.
You asked the Plan to pre-approve ambulance services. You say that these services are medically necessary. The Plan denied your request. The Plan says that you are not bed bound and could be transferred by alternate means of transportation.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 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 ambulance services. Our reviewer says that ambulance services are not medically reasonable and necessary for the enrollee. The record indicates that you fell in the nursing home and were unable to ambulate. After being evaluated in the emergency department and admitted for further care, you were transported back to the living facility. The provided records are insufficient to determine your medical need to be transported by ambulance. Our physician reviewer found that your condition does not meet Medicare criteria for ambulance 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 ambulance services have not been met. Therefore, we decided that the Plan does not have to pre-approve ambulance services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on May 19, 2021.
You asked the Plan to pay for periodontal maintenance. You say that this was a preventative service and should be covered as a preventative cleaning. The Plan denied your request. The Plan says this service is 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 pay for the periodontal maintenance (D4910) provided on May 19, 2021.
Your complaint about services covered or not covered by the Plan's supplemental benefit and potential lack of information from the Plan's contracted provider regarding covered services 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for nutrition therapy provided by an out-of-network provider on
July 17, 2020, and August 20, 2020.
You asked the Plan to pay for nutrition therapy. You say that you are requesting reconsideration to be
processed based on medical necessity. The Plan denied your request. The Plan says this provider is not a
network provider with the Plan and the services were not approved in advance.
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 nutrition therapy provided by an out-of-network
provider on July 17, 2020, and August 20, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (88321) provided on February 26, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled service.
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 88321 has a bundled relationship with code 88323 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 services (88321) provided on February 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for incomplete endodontic therapy (D3332) provided on February 2, 2021.
You asked the Plan to pay for incomplete endodontic therapy. You say that the service was necessary. 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 incomplete endodontic therapy (D3332) provided on February 2, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve power wheelchair repairs for the enrollee.
You asked the Plan to pre-approve the repairs. You say that this is medically necessary. The Plan denied your request. The Plan says that it is not clear that the repaired wheelchair would be safe to use for a long time after being repaired.
The Plan follows Medicare rules. Medicare rules say that services are covered when they are 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 repairs. Our reviewer says that the requested repairs are medically reasonable and necessary. Our physician reviewer found the equipment is less than 5 years old and the wear and tear is reparable. The documentation does not indicate damage is from use beyond normal wear and tear therefore the requested repairs are medically necessary and a replacement is not medically necessary. The criteria for repairs have been met. 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 repairs have been met. Therefore, we decided that the Plan has to pre-approve power wheelchair repairs for the enrollee.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on May 17, 2021.
You asked the Plan to waive the copayment for the ER visit. You say that you went to the ER because the clinic could not run a test that you needed. 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 $120 copayment for emergency room visits. You have been asked to pay a $120 copayment for the ER visit. This copayment applies regardless of the reason for the ER visit. 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 the emergency room (ER) visit you had on May 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for an excision of a tumor of the soft tissue of the neck or
anterior thorax (21555) performed on April 22, 2021.
You asked the Plan to pay for an excision of a tumor. You say that the requested service was a medical
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1,
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current
Procedural Terminology (CPT) code 21555. The Medicare Fee Schedule Database contains a surgical indicator
of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically
necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for an
excision of a tumor have not been met. Therefore, we decided that the Plan does not have to pay for an excision
of a tumor of the soft tissue of the neck or anterior thorax (21555) performed on April 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Rezum procedure.
You asked the Plan to pre-approve the Rezum procedure. You say that the requested Rezum procedure is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested Rezum procedure.
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 Rezum procedure. Our reviewer says that the enrollee does not meet criteria for the requested Rezum procedure. Our physician reviewer found the enrollee is with benign prostatic hyperplasia (BPH) and lower urinary tract symptoms and erectile dysfunction. He underwent greenlight laser procedure in 2018 and has done well since then. He voids 2-3 times per night. He underwent cystoscopy on 6/27/21 and was found to have lateral lobe hypertrophy. The enrollee does not meet LCD criteria for the requested Rezum procedure. Specifically, prostate volume, IPSS and flow rate were not 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 Rezum procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Rezum procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Xgeva injection provided on April 14, 2021.
You asked the Plan to waive the coinsurance for the Xgeva injection (J0897). You say that you were not charged for the first three injections. The Plan denied your request. The Plan says the provider was unable to bill for the first three injections as they denied for no authorization but now you have been charged the coinsurance 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 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay 20% coinsurance for the Xgeva injection (J0897). The Xgeva injection (J0897) falls within the Medicare Part B prescription drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the Xgeva injection provided on April 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (CPT code 99214) provided to the enrollee on October 5, 2020, by an out-of-network provider.
You asked the Plan to pay for the office visit. You say that the claim should be paid. The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider, and the services were not urgent or emergent, nor were they approved in advance.
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 items/services at issue in this appeal. 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 office visit (CPT code 99214) provided to the enrollee on October 5, 2020, by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
You asked the Plan to pre-approve the compression stockings. You say that this is medically necessary. The Plan denied your request. The Plan says this is meant solely to manage lower leg swelling and varicose veins.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 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 A6530.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from March 19, 2021, through March 22, 2021.
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient stay was medically necessary. The Plan denied your request. The Plan says that the inpatient stay was not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found The record show that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier emergency department and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from March 19, 2021, through March 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex 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 a review of the current medical literature indicates that this service is considered experimental and investigational.
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 this device is experimental. More research is needed to show safety and efficacy of the device. 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 the Vertiflex device for the enrollee.