Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox injections.
You asked the Plan to pre-approve Botox injections. You say that this is medically necessary. The Plan denied
your request. The Plan says this is not supported for the enrollee's condition.
The Plan follows Medicare rules. Medicare rules say that Botulinum toxins (Botox), will be considered
medically reasonable and necessary when administered for treatment of FDA-labeled indications and Off-label
indications as described in the rules section.
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 Botox injections. Our reviewer says
that the requirements for coverage of Botox injections have not been met. Our physician reviewer found based
on the medical records provided, there is no documentation that the Botox is being requested for a Food and
Drug Administration-approved indication or an off-label indication described in the Local Coverage
Determination. The provided records do not document a diagnosis of achalasia of any other medically accepted
indication for Botox.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Botox injections have not been met. Therefore, we decided that the Plan does
not have to pre-approve Botox injections
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physician's services provided on
June 1, 2021, and June 4, 2021.
You asked the Plan to waive the copayment for physician's services. The Plan denied your request. The Plan says that the Plan reduced the copayment to $25.
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 $25 copayment for Physician/Practitioner services, including doctor's office visits. You have been asked to pay a $25 copayment for physician's services. The physician's services falls 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 copayment for physician's services provided on June 1, 2021, and June 4, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on May 13, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable 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. We find that the laboratory services are not supported in the medical record. Specifically, If a laboratory procedure produces multiple reportable test results, only a single code shall be reported for the procedure. If there is no code that describes the procedure, the laboratory shall report a miscellaneous or unlisted procedure code with a single unit of service. Review of the file shows that the services rendered were billed with more than a single code. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met.
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on May 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a medial branch block at spinal level 5 (L5).
You asked the Plan to pre-approve a medial branch block at L5. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for the requested procedure have not been met.
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 a medial branch block at L5.
Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee had previously had injections at L3, L4, and L5 with 100% relief for two hours, which subsequently decreased to 50%. The provided record does not support unique circumstances nor supply sufficient documentation of medical necessity on appeal why a third level is needed. The elements of the coverage criteria are not satisfied. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a medial branch block at L5 have not been met. Therefore, we decided that the Plan does not have to pre-approve a medial branch block at spinal level 5 (L5).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation services.
You asked the Plan to pre-approve radiofrequency ablation services. You say that this request is medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met as the frequency has been exceeded.
The Plan must follow Medicare rules. Medicare rules say that for each covered spinal region no more than 2 radiofrequency sessions will be reimbursed per rolling 12 months. We looked at the file and Medicare rules. In this case, the enrollee has received two radiofrequency ablation sessions on January 12, 2021, and March 12, 2021. Therefore, the 2 covered radiofrequency services have been exhausted at this time. Based on this information, we decided that Medicare rules for coverage of radiofrequency ablation services have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited oral evaluation (D0140), an intraoral periapical
radiographic image (D0220), pulp vitality tests (D0460), a cone-beam computed tomography capture (D0364)
and does not have to pay an additional amount for endodontic therapy (D3330) provided on June 21, 2021.
You asked the Plan to pay for a limited oral evaluation, an intraoral periapical radiographic image, pulp vitality
tests, a cone-beam computed tomography capture, and to pay an additional amount for endodontic therapy.
You say that you want the plan to reimburse you for these services. The Plan denied your request. The Plan
says the limited oral evaluation is a covered benefit, but you have exceeded the frequency limit of two per
calendar year. The intraoral periapical radiographic image is a covered benefit, but you have exceeded the
frequency limit of one each calendar year. The pulp vitality tests and cone-beam computed tomography capture
are not covered benefits. The endodontic therapy was processed at the correct in-network benefit amount.
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 a limited oral evaluation, an intraoral periapical radiographic image, pulp vitality tests, a conebeam
computed tomography capture, and does not have to pay an additional amount for endodontic therapy
have not been met. Specifically, the record shows that you had exceeded the frequency limit for the limited oral
evaluation prior to this service on February 10, 2021, and February 26, 2021. The record also shows that you
had exceeded the frequency limit for the intraoral periapical radiographic image on February 10, 2021.
Additionally, pulp vitality tests and cone-beam computed tomography capture are not covered benefits. Lastly,
the endodontic therapy was processed at the correct in-network benefit amount. Therefore, we decided that the
Plan does not have to pay for a limited oral evaluation (D0140), an intraoral periapical radiographic image
(D0220), pulp vitality tests (D0460), a cone-beam computed tomography capture (D0364) and does not have to
pay an additional amount for endodontic therapy (D3330) provided on June 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional maintenance chiropractic services.
You asked the Plan to pre-approve additional maintenance chiropractic services. You say that these additional services continue to be medically reasonable and necessary for the enrollee's condition. The Plan denied your request. The Plan says the benefit has been exhausted at this time.
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance care. We looked at the file and Medicare rules. In this case, the Plan has paid for the contractual obligation of 18 complimentary chiropractic services. Based on this information, we decided that Medicare rules for coverage of additional maintenance chiropractic services have not been met. Therefore, we decided that the Plan does not have to pre-approve additional maintenance chiropractic services
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and complete
mandibular denture (D5120).
You asked the Plan to pre-approve the complete dentures. You say that you never received the dentures that
were billed to the Plan. You also say that you need the dentures for personal wellness and to be able to eat
properly. The Plan denied your request. The Plan says these services exceed the maximum counts allowed per
period.
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, complete maxillary denture (D5110)
and complete mandibular denture (D5120) are each limited to one procedure every five plan years. The record
shows that you received a complete maxillary denture (D5110) and complete mandibular denture (D5120) on
June 23, 2021 and your complete maxillary denture (D5110) and complete mandibular denture (D5120)
benefits have been exhausted.
Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and complete mandibular denture (D5120).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lumbar spine (72148).
You asked the Plan to pre-approve an MRI. You say that this is medically necessary. The Plan denied your request. The Plan says this is not indicated at this time.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only 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 an MRI. Our reviewer says that the requested MRI is not medically necessary. Our physician reviewer found based on the records provided, not enough conservative measures have been tried and failed. Physical therapy for back pain is needed. There are no red flags for an MRI at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lumbar spine (72148).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the chemotherapy drug administration (96413, J0897, J9299) provided on February 2, 2021.
You asked the Plan to waive the coinsurance for the chemotherapy. You say that you feel this was processed in error and the amount you are being billed is not your responsibility. The Plan denied your request. The Plan says this claim was processed correctly, and your coinsurance was assessed in accordance with your contract. You received chemotherapy drugs on the date in question. These services require 20% 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 20% coinsurance for chemotherapy drugs.
You have been asked to pay 20% coinsurance for the chemotherapy drugs and administration. The provider billed $86,321.50 for the services at issue. The Plan's allowed cost for these services is $16,393.62. You are responsible for 20% coinsurance on the allowed amount for chemotherapy drugs ($16,393.62 x 20% coinsurance = $3,278.73) 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 chemotherapy drug administration (96413, J0897, J9299) provided on February 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a medical eye examination (92004) provided on May 10, 2021.
You asked the Plan to waive the copayment for a medical eye examination. You say that the service should be covered with no cost to you. The Plan denied your request. The Plan says the copayment was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 copayment for medical eye examinations. You have been asked to pay a $35 copayment for a medical eye examination. The service at issue falls within the vision 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 a medical eye examination (92004) provided on May 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99202) and manual therapy techniques (97140) provided June 8, 2021.

You asked the Plan to pay for the office visit and manual therapy techniques. You say that you would like these claims reprocessed and approved for payment. The Plan denied your request. The Plan says chiropractic care other than manual manipulation of the spine is not covered.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 

The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the office visit (99202) and manual therapy techniques (97140) provided June 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for home visit for assistance with activities of daily living and personal care provided on March 1 - March 31, 2021.

You asked the Plan to pay for the home visits. You say that the services in dispute were medically necessary. The Plan denied your request. The Plan says the services provided were custodial and are not a covered benefit.

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. The case file shows that your family member is unable to care for you and that an aide was needed for toileting help, grooming, bathing, cooking, and managing routine medication considerations. The case file does not show that the services billed were for skilled care. Based on this information, we decided that Medicare rules for coverage of the home visits 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 home visit for assistance with activities of daily living and personal care provided on March 1 - March 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued chiropractic manipulative treatment.

You asked the Plan to pre-approve the treatment. You say that this is medically necessary. The Plan denied your request. The Plan says the records do not provide evidence that you continue to respond to the ongoing course of chiropractic intervention.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 

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 treatment Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found in this case, the record indicates that you have segmental somatic dysfunction and sprain. The provided records do not document physical examination or radiographic evidence of subluxation. The elements of the coverage rule are not satisfied. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve continued chiropractic manipulative treatment.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the lab services provided on July 15, 2021.

You asked the Plan to waive the copay for the lab services. You say that your physician does not have a lab in
her office. The Plan denied your request. The Plan says the claim processed 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 $40
copay for each freestanding laboratory visit.

You have been asked to pay a $40 copay for the lab services. The services fall within the laboratory services
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 copay for the lab services provided on July 15,
2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (procedure codes 12052 and 12002) provided to the enrollee on January 9, 2021.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the denied codes remain 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 the denied codes is: 

CPT 12052: 

Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5.0 cm 

CPT 12002: 

Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.6 cm to 7.5 cm

We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found the procedure report documents multiple procedures; therefore, an appropriate modifier should be appended to both CPT 12052 and CPT 12002. 

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 surgical services (procedure codes 12052 and 12002) provided to the enrollee on January 9, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) care, provided on June 1, 2021, through June 9, 2021.

You asked the Plan to waive the copayment for the SNF care. You say that the service should be covered. The Plan denied your request. The Plan says the cost share was applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 copayment each day 21 through 100 for skilled nursing facility (SNF) care.

You have been asked to pay a $20 copayment each day 21 through 100 for the SNF care. This service falls within the skilled nursing facility (SNF) care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. The records show you received SNF care for 20 days in the beginning of 2021 and were charged a copayment for 8 out of the 9 days you received SNF care for June 1, 2021, through June 9, 2021. 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 skilled nursing facility (SNF) care, provided on June 1, 2021, through June 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapy services represented by code 97530 provided on November 25, 2019.

You asked the Plan to pay for the therapy services. 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 the services of an OTA shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of occupational therapy have not been met. Specifically, the billing provider is a nurse practitioner, and not a licensed therapist. As such, OTA services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for the therapy services represented by code 97530 provided on November 25, 2019.