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

We decided that the Plan does not have to pre-approve expandable controller identified with code E2377,
harness identified with code E2313, and electrical connection identified with code E2311.
You asked the Plan to pre-approve expandable controller, harness, and electrical connection. You say that you
would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested items
are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that wheelchair accessories are only covered for certain
indications.
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 expandable controller, harness, and
electrical connection. Our reviewer says that the documentation does not support that the requested items are
medically reasonable or necessary. Our physician reviewer found the enrollee has a past medical history of a
traumatic brain injury and a stroke who requires a power wheelchair for mobility. Although the records indicate
the enrollee has upper extremity tremors and left upper extremity weakness, there is no documentation of right
upper extremity weakness which would prevent the enrollee from operating the wheelchair's power options
with their own switches. Records indicate the enrollee is capable of drinking fluids on their own and
administering own medication. Therefore, the enrollee does not meet criteria for the requested items.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of expandable controller, harness, and electrical connection have not been met.
Therefore, we decided that the Plan does not have to pre-approve expandable controller identified with code
E2377, harness identified with code E2313, and electrical connection identified with code E2311.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance, lumbar or sacral, single level (64483) and the triamcinolone acetonide injection (J3301) rendered by the out-of-network (OON) provider on January 12, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance, lumbar or sacral, single level (64483) and the triamcinolone acetonide injection (J3301) rendered by the out-of-network (OON) provider on January 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0675).
You asked the Plan to pay for a pneumatic compression device. You say that the item is medically necessary. The Plan denied your request. The Plan says The pneumatic compression device and/ or supplies is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery, at home, or in any setting.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0675).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a duplex scan provided on June 28, 2021.
You asked the Plan to waive the copayment for a duplex scan. You say that you were not informed that you would owe a double copayment. 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 $20 copayment for outpatient diagnostic tests provided at a specialist's office. You have been asked to pay a $20 copayment for a duplex scan. A duplex scan falls within the outpatient diagnostic tests and therapeutic services and supplies 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 a duplex scan provided on June 28, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral/facial photographic image (D0350), provided on July
14, 2021.
You asked the Plan to pay for the oral/facial photographic image. You say that the service was medically
necessary. The Plan denied your request. The Plan says this service 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 the
oral/facial photographic image (D0350), provided on July 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a core buildup (D2950) and a crown-porcelain/ceramic (D2740) provided by an out-of-network provider on March 26, 2021.
You asked the Plan to pay for a core buildup and a crown-porcelain/ceramic. You say that you were never told that this provider was out-of-network. You say that you would like a refund. The Plan denied your request. The Plan says the services that were provided are not covered services.
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 a core
buildup (D2950) and a crown-porcelain/ceramic (D2740) provided by an out-of-network provider on March 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair and related accessories.
You asked the Plan to pre-approve the requested wheelchair. The Plan denied your request. The Plan says the enrollee does not have a qualifying diagnosis for the requested wheelchair.
The Plan follows Medicare rules. Medicare rules say that power mobility devices are only covered under certain medical indications. 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 requested wheelchair. Our physician reviewer found that the enrollee has a past medical history of chronic obstructive pulmonary disease, right foot pain due to a traumatic injury, weakness, gastroesophageal reflux disease, hypertension and hyperlipidemia. He has shortness of breath and difficulty ambulating. Based on the medical records, there is no documentation that the enrollee has a mobility limitation due to a neurological condition, myopathy, or a congenital skeletal deformity. The records indicate the enrollee's mobility limitation is primarily due to his respiratory condition and right foot pain due to trauma.
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 requested wheelchair. have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair and related accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for specialist services provided on June 15, 2021.
You asked the Plan to waive the coinsurance for specialist services. You say that you were not made aware that you would owe this much and cannot afford the charges. 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 30% coinsurance for point of service physician/practitioner services, including doctor's office visits. You received specialist services from a point of service physician on June 15, 2021. Therefore, you are responsible to pay your share of the cost-sharing charges. The total allowed amount is $297.45 and 30% of that is $89.23. You have been asked to pay the total coinsurance amount of $89.23 for specialist services. Specialist services fall within the physician/practitioner services, including doctor's office visits 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 specialist services provided on June 15, 2021
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes (99291) provided June 13, 2021.
You asked the Plan to pay for the critical care. You say that the coding is supported by the documentation. The Plan denied your request. The Plan says code 99291 is not supported for the service performed on June 13, 2021.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate Current Procedural Terminology (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 critical care. Our reviewer says that that the reviewed documentation indicates that CPT code 99291 (1 Unit) remains not supported. This requested code is included in CPT code 31624; therefore, it cannot be separately reimbursed. Of note, there is an appropriate modifier (modifier 25) that should be used to support a significant, separately identifiable evaluation and management service. Our reviewer found CPT code 99291 is not supported for date of service June 13, 2021. 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 critical care have not been met. Therefore, we decided that the Plan does not have to pay for the critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes (99291) provided June 13, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrocardiogram services (93042) provided on April 28, 2021.
You asked the Plan to pay for the electrocardiogram services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says this claim has denied correctly based on the PTP 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, we have confirmed that code 93042 is a column II code to column I code 93010. This claim has an edit of 0 which indicates associated modifiers are not allowed and will not 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 electrocardiogram services (93042) provided on April 28, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to hold you harmless for the 3-surface filling (D2332) and 4-surface filling (D2394) provided on June 10, 2021.
You asked the Plan to pay for the dental services. You say that your dentist advised they would do the fillings for no charge. You say that now the dentist is going back on what they said. You say that this had to be done so you feel you should not be responsible for paying this. The Plan denied your request. The Plan says that the fillings are not listed as covered services.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. You were referred for the dental services by a contract provider. The file does not show that the Plan provided notice that the dental services would not be covered. Under Medicare rules, this means the dental services is considered approved by the Plan. Additionally, the record shows that you signed a treatment plan that indicates the fillings would be covered. Therefore, we decided that the Plan has to hold the enrollee harmless for the 3-surface filling (D2332) and 4-surface filling (D2394) provided on June 10, 2021.
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: Unfavorable

We decided that the Plan does not have to pay for the critical care services (99291) provided on December 16, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the records do not support this service.
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. We looked at the file and Medicare rules. The documentation submitted does not contain medical records for the date of service in question. Without records, it cannot be confirmed that Medicare coverage criteria have been met.
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 critical care services (99291) provided on December 16, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the custodial care, provided on August 19, 2020, through December 30, 2020.
You asked the Plan to pay for the custodial care. You say that the services were medically necessary. The Plan denied your request. The Plan says custodial care is not a covered service.
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from trained medical or paramedical staff, is not covered.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the custodial care have not been met. Specifically, we find that the services at issue in this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pay for the custodial care, provided on August 19, 2020, through December 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the contact lens (V2520), provided on June 24, 2021.
You asked the Plan to pay for the contact lens. You say that the item should be covered. The Plan denied your request. The Plan says you have exhausted your benefit for this item.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers contact lenses up to the annual benefit limit of $200 for eyewear. We looked at the file and the Plan's rules. You have exhausted your Plan's benefit for contact lenses. Based on this information, we decided that the Plan's rules for coverage of the contact lens have not been met. Therefore, we decided that the Plan does not have to pay for the contact lens (V2520), provided on June 24, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy services coded S9367 provided
from May 13, 2021, to May 19, 2021.
You asked the Plan to pay for the home infusion therapy services. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.
The Plan must follow Medicare rules. Medicare rules 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 S9367 is home infusion therapy, total parenteral nutrition
(tpn); more than two liters but no more than three liters per day, administrative services, professional pharmacy
services, care coordination, and all necessary supplies and equipment including standard tpn formula (lipids,
specialty amino acid formulas, drugs other than in standard formula and nursing visits coded separately), per
diem.
We find that CPT code S9367 is not supported in the medical record. Specifically, this code has a status code
of "I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code
for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for
coverage of the home infusion therapy services have not been met. Therefore, we decided that the Plan does
not have to pay for the home infusion therapy services coded S9367 provided from May 13, 2021, to May 19,
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids provided on May 27, 2021.
You asked the Plan to pay for hearing aids. The Plan denied your request. The Plan says you must use a Plan hearing aid provider.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. We looked at the file and the Plan's rules. The file shows that the hearing aids were not provided by the Plan's hearing aid provider. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids provided on
May 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical extractions (D7210), provided on July 10, 2020, and June 25, 2021.
You asked the Plan to pay for the surgical extractions. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were received out-of-network and they are not listed as covered benefits in the Plan's benefit chart.
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 surgical extractions (D7210), provided on July 10, 2020, and June 25, 2021
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion provided on April 15, 2021.

You asked the Plan to pay for the home infusion. You say that the attached nursing visit notes should be
reviewed for reconsideration of payment. The Plan denied your request. The Plan says the codes are not valid
for Medicare billing purposes.

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 99601 is home infusion/specialty drug administration, per
visit (up to 2 hours). The CPT Code Manual definition of code 99602 is home infusion/specialty drug
administration, per visit (up to 2 hours); each additional hour (List separately in addition to code for primary
procedure).

We find that CPT code 99601 and 99602 are not supported in the medical record. Specifically, CPT code
99601 and 99602 have a status indicator of I. This means that CPT code 99601 and 99602 are not valid for
Medicare billing purposes. Based on this information, we decided that Medicare rules for coverage of the home
infusion have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion
provided on April 15, 2021.