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

We decided that the Plan does not have to pre-approve a cone beam computed tomography (CT) capture and
interpretation (D0365).
You asked the Plan to pre-approve a cone beam CT capture and interpretation. You say that you do not agree
with the denial of the requested service. The Plan denied your request. The Plan says the requested service is
not covered under your benefit package.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a
cone beam computed tomography (CT) capture and interpretation (D0365).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Flexitouch pneumatic compression device (E0652,
E0667).
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your
request. The Plan says there are network providers available.
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 based on the medical records provided, there is no documentation that there is a specific need for the
Flexitouch brand from an out-of-network provider as opposed to an equivalent device from an in-network
provider.
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 Flexitouch pneumatic compression device (E0652, E0667).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341).  You asked the Plan to pre-approve periodontal scaling and root planing. You say that you are requesting reconsideration because you need a deep cleaning. The Plan denied your request. The Plan says the requested service is not covered under your benefit plan.  Medicare generally does not cover dental services. The Plan follows the same rule.  The services you are asking the Plan to pre-approve 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. The records confirm that you did not purchase a dental rider with the Plan. Therefore, we decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the power seat elevation system (E2300), expandable
controller (E2377), harness (E2313), and electronic connection (E2311).
You asked the Plan to pre-approve the wheelchair accessories. You say that the items are medically necessary.
The Plan denied your request. The Plan says the power seat elevation system does not primarily serve as
medical in nature and there is no need to control power options through a joystick
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
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 for the wheelchair accessories. Our reviewer says that
the wheelchair accessories are not medically necessary. Our physician reviewer found the enrollee has adequate
upper extremity strength and function to operate the wheelchair's power options with their own switches.
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 accessories have not been met. The power seat elevation system
does not serve a purpose that is primarily medical in nature. This item is available to the general public and
would be helpful even to those who are not sick or injured. The expandable controller, harness and electronic
connection are not medically necessary. Therefore, we decided that the Plan does not have to pre-approve the
power seat elevation system (E2300), expandable controller (E2377), harness (E2313), and electronic
connection (E2311).
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the cochlear device implantation (69930) provided on August 16, 2021.  You asked the Plan to pay for the cochlear device implantation. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no payment may be made for hearing services.  The Plan must follow Medicare rules. Medicare rules say that coverage for cochlear implants is provided when there is a diagnosis of bilateral moderate-to-profound sensorineural hearing impairment.  We looked at the file and Medicare rules. In this case, the record does not indicate that there is a diagnosis of bilateral hearing impairment. On the contrary, there is only a diagnosis of moderate-to-profound hearing impairment in the left ear. Based on this information, we decided that Medicare rules for coverage of the cochlear device implantation have not been met. Therefore, we decided that the Plan does not have to pay for the cochlear device implantation (69930) provided on August 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the resin-based composite (D2392) provided on September 20, 2021.  You asked the Plan to pay for the resin-based composite. You say that you advised the provider not to render services over your maximum benefit because you live on a fixed income and could not spend extra money out-of-pocket. The Plan denied your request. The Plan says you reached your maximum benefit allowed amount per calendar year.  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 Plan offers a $3,500 annual dental benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are responsible for the full charges of any additional dental services. The record shows that you met the annual maximum benefit on June 24, 2021 and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the resin-based composite (D2392) provided on September 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies (K0553), provided on February 9, 2021.  You asked the Plan to pay for the CGM supplies. You say that the items are medically necessary. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order for the billed date of service / for the billed item(s).  The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.   The record does not contain a valid physician order. The order was not both signed and dated by the ordering physician. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies (K0553), provided on February 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoperative perfusion services provided on June 23,
2021.
You asked the Plan to pay for the services provided. You say that the claim should be processed separately.
The Plan denied your request. The Plan says the services are included in the payment made to the facility.
The plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other
than the facility for services furnished to a beneficiary.
We looked at the file and the rules. The records show that the enrollee was an inpatient at the time the services
were provided. The facility must furnish all necessary covered services to the beneficiary either directly or
under arrangements made with outside providers. This service was provided via arrangement of the facility.
Payment for this service would have been included under the facility claim. Payment to you for this service is
the responsibility of the facility. Therefore, we decided that the Plan does not have to pay for the intraoperative
perfusion services provided on June 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve porcelain/ceramic crowns (D2740) for tooth #8 and tooth #28.  You asked the Plan to pre-approve crowns. You say that these services are necessary and should be covered. The Plan denied your request. The Plan says crowns are not medically necessary for these teeth. The record shows that tooth #28 has an inadequate fill from a previous root canal treatment, and alternative services would be more appropriate to cap this tooth. Tooth #8 has a compromised periodontal condition, and it appears that there is a poor prognosis for this tooth than cannot be changed with a crown. Please talk to your dentist about other treatment options.  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 crowns when the services are medically necessary and reasonable.   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 crowns. Our reviewer says that the documentation provided does not meet the criteria for coverage for crowns for teeth #8 and #28. Our physician reviewer found that the record shows that the root canal filling in tooth #28 does not appear to be adequate, and the bone support of tooth #8 is severely compromised. Crowns for these teeth are not medically reasonable in this case.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of crowns have not been met. Therefore, we decided that the Plan does not have to pre-approve porcelain/ceramic crowns (D2740) for tooth #8 and tooth #28.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the application of a multi-layer compression system provided on September 3, 2021.  You asked the Plan to waive the coinsurance for the application of a multi-layer compression system. You say that you feel that the charges are too high and that you should only owe a $20 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 $95 copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers.   The medical records show that you received the application of a multi-layer compression system, at an outpatient hospital facility, on September 3, 2021. The application of a multi-layer compression system is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $95 copayment.   You have been asked to pay a $95 copayment for the application of a multi-layer compression system. The application of a multi-layer compression system falls within the outpatient surgery and other medical 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 coinsurance for the application of a multi-layer compression system provided on September 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (99220, 99497) provided on February 11, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services 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.
In this case, the CPT Code Manual definition of code 99220 is "Initial observation care, per day, for the
evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with
the nature of the problem(s) and the patient's and/or family's needs.
Usually, the problem(s) requiring admission to outpatient hospital "observation status" are of high severity.
Typically, 70 minutes are spent at the bedside and on the patient's hospital floor or unit." The CPT Code
Manual definition of code 99497 is "Advance care planning including the explanation and discussion of
advance directives such as standard forms (with completion of such forms, when performed), by the physician
or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s),
and/or surrogate".
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 99220
and 99497 is not supported by the records provided. Our reviewer found that the medical records provided do
not include sufficient documentation to validate these services were performed on February 11, 2021;
therefore, these services 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 the services (99220, 99497) provided on February 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the pain management services provided on September 7, 2021.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the services are not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find that a nutria-pharmaceutical injection was billed with multiple drug codes. The multiple drug codes reported on this claim refer to a pre-filled compounded drug/vitamin syringe. The rules require that any compounded drug be billed using the not otherwise classified code J7999. As this compounded drug was not billed properly, payment cannot be made.
The file shows that vasopneumatic device therapy was provided. We looked at the file and the rules. Medicare rules say that Further treatment of lymphedema by a provider after the educational visits is generally not medically necessary.
The file shows that electrical nerve stimulation was provided. We looked at the file and the rules. It is inappropriate for an enrollee to visit his/her physician, physical therapist, or an outpatient clinic on a continuing basis for treatment of pain with electrical nerve stimulation. Furthermore, a review shows that the physical therapy services were rendered by nurse practitioner who is not licensed to provide physical therapy in the state where the services were provided.
Based on this information, we decided that Medicare rules for coverage of the services at issue in this case have not been met. Therefore, we decided that the Plan does not have to pay for the pain management services provided on September 7, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the intraoral - periapical first radiographic image (D0220) and intraoral - periapical each additional radiographic image (D0230) provided September 16, 2021.  You asked the Plan to pay for the periapical x-rays. You say that you don't understand why this service isn't covered. The Plan denied your request. The Plan says these x-rays are not covered under your benefits.  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 intraoral - periapical first radiographic image (D0220) and intraoral - periapical each additional radiographic image (D0230) provided September 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the testing services provided on April 10, 2021.  You asked the Plan to pay for the services provided. You say that the testing was ordered to determine if there was a more effective therapy to treat the enrollee. The Plan denied your request. The Plan says the place of service must reflect the location of the enrollee when the specimen was obtained.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.  The claim information lists a place of service as an independent laboratory. We looked at the file and the rules. If an independent lab bills for services, the place where the sample was taken is reported as the place of service. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the testing services provided on April 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the medical services coded as 64490-50, 99156, 99157, A4550 provided on May 26, 2021.  You asked the Plan to pay for the medical services as billed. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says this claim has denied correctly.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2.  We have confirmed that codes 99156 and 99157 are both column II codes to column I code 64490. 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.  Regarding CPT code A4550, this code has a status indicator of B meaning that payment for this service is always bundled into another procedure. Separate payment is not made for CPT code A4550.  Finally, in this case, the MUE for CPT code 64490 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of code 64490 have not been met.  Therefore, we decided that the Plan does not have to pay for the medical services coded as 64490-50, 99156, 99157, A4550 provided on May 26, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the maximum out-of-pocket amount and the coinsurance for a positron emission tomography (PET) scan and drugs from April 6, 2021, to August 19, 2021.
You asked the Plan to waive the maximum out-of-pocket amount and the coinsurance for a PET scan and drugs. You say that you hit your maximum out-of-pocket amount prior to April 6, 2021. The Plan denied your request. The Plan says the maximum out-of-pocket was not hit until August 19, 2021, and the proper cost share 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 $1000 maximum out-of-pocket during the plan year for covered Medicare Part A and Part B services received from both in-network and out-of-network providers. Prior to April 6, 2021, you maximum out-of-pocket was $570.17. With a charge of $419.63 for the PET scan that brought your total maximum out-of-pocket total to $989.80 ($570.17 prior out-of-pocket + $419.63). Your contract with the Plan also clearly says that you must pay a 20% coinsurance for each Medicare-covered Part B drug and nonchemotherapy drugs to treat cancer.
With a total amount allowed on August 19, 2021, of $43.76 the 20% coinsurance was $8.75 ($43.76 total cost x 20% coinsurance) which also brought the maximum out-of-pocket to $988.55 (989.80 out-of-pocket + 8.75). Also on August 19, 2021, another charge of $94.78 with a copayment of $1.25 was applied which brought the maximum out-of-pocket amount to $1000. You have been asked to pay a $420.88 maximum out-of-pocket and a $8.75 coinsurance for the PET scan and drugs. The maximum out-of-pocket falls within the What is the most you will pay for Medicare Part A and Part B covered medical services benefit category. The drugs fall 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 maximum out-of-pocket amount and the coinsurance for a positron emission tomography (PET) scan and drugs from April 6, 2021, to August 19, 2021.