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

We decided that the Plan does not have to pay for the removal of an impacted tooth, partially bony (D7230 x 3) provided on August 11, 2021.
You asked the Plan to pay for the dental services. You say that you received a bill for $207. You say that both you and the dental office were given misinformation from the plan. You say that you had to go to the dentist to get procedures on 4 wisdom teeth. You say that the surgeon told you they accepted your insurance. You also say that the services should be covered. The Plan denied your request. The Plan says that removal of an impacted tooth, partially bony, is not listed as a covered service.
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 removal of an impacted tooth, partially bony (D7230 x 3) provided on August 11, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of an interspinous spacer device (Vertiflex).
You asked the Plan to pre-approve Vertiflex. You say that the enrollee has failed conservative treatment and is a good candidate for Vertiflex. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because Vertiflex is experimental/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 Vertiflex. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental/investigational. More research is needed to show its safety and efficacy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Vertiflex have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of an interspinous spacer device (Vertiflex).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a breast prothesis billed to the enrollee for June 9, 2021.
You asked the Plan to pay for this item. You say that this claim should be paid. The Plan denied your request. The Plan says the claim was not submitted with a valid physician order.
The Plan must follow Medicare rules. The rules state that durable medical equipment is covered only when a valid physician order is present. The record does not contain a valid physician order. 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 a breast prothesis billed to the enrollee for June 9, 2021.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a laparoscopic-assisted hysterectomy.
You asked the Plan to pre-approve a laparoscopic-assisted hysterectomy. You say that a laparoscopic-assisted hysterectomy is medically necessary. The Plan denied your request. The Plan says that in order to qualify for this surgical removal of the uterus, the medical records need to show that the enrollee has tried other treatments for this condition, like medicines or that there is a reason why the enrollee can't try these treatments first.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 a laparoscopic-assisted hysterectomy. Our reviewer says that the requested laparoscopic-assisted hysterectomy is considered medically reasonable and necessary in this case. Our physician reviewer found that the record indicates that the procedure is being requested for persistent menorrhagia following a year of amenorrhea. The medical record indicates that the enrollee has significant blood loss and becomes symptomatic. The record provided establishes the medical necessity and reasonableness, as defined by Medicare rules. The elements of the coverage criteria are satisfied. The requested service is recommended. 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 laparoscopic-assisted hysterectomy have been met. Therefore, we decided that the Plan has to pre-approve a laparoscopic-assisted hysterectomy.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pneumatic compressor, segmental home model with calibrated gradient pressure (CPT code E0652) and segmental pneumatic appliance for use with pneumatic compressor (CPT code E0667), for the enrollee.
You asked the Plan to pre-approve the DME. You say that the enrollee continues to demonstrate persistent symptoms despite adherence to conservative therapies. You state the DME is medically necessary. The Plan denied your request. The Plan says there is no documentation in the clinical record that the enrollee has lymphedema extending onto the chest, trunk, and/or abdomen that extends past the limits of a standard compression sleeve. The Plan states there is no indication of at least four (4) weeks of regular, daily, multiple-hour home usage of the E0650 or E0651, after careful in-person fitting, training, and supervision by a technician who is skilled in, and who regularly, and successfully uses the appliance provided.
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 DME. Our physician reviewer found there is insufficient documentation in the provided record that the enrollee has lymphedema extending onto the chest, trunk, and/or abdomen that extends past the limits of a standard compression sleeve. Therefore, the requested pneumatic compressor with appliance will be considered not medically necessary 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 the DME have not been met. Therefore, we decided that the Plan does not have to pre-approve pneumatic compressor, segmental home model with calibrated gradient pressure (CPT code E0652) and segmental pneumatic appliance for use with pneumatic compressor (CPT code E0667), for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the screening testing provided on July 1, 2021.
You asked the Plan to pay for the screening testing. You say that you would like reconsideration because the testing was medically necessary. The Plan denied your request. The Plan says these services are not authorized because screening testing is not a Medicare benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The test at issue in this appeal, the screening testing, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Additionally, the documentation submitted does not include clinical information to verify why this testing was ordered or if it was medically necessary. Therefore, we decided that the Plan does not have to pay for the screening testing provided on July 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for outpatient mental health care provided by
an out-of-network provider from July 3, 2021, to July 24, 2021.
You asked the Plan to waive the deductible for the out-of-network outpatient mental health care. You say that
these bills are a financial hardship for the enrollee. You stated that you were quoted a $40 copayment per
session benefit for these services. You said that you were not notified of the deductible prior to the services.
The Plan denied your request. The Plan says the member had not yet met her deductible at the time of these
services.
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 a $750 deductible which applies to outpatient mental health care with
an out-of-network provider.
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible which
applies to outpatient mental health care with an out-of-network provider. This cost sharing is a contractual
obligation that had not been met at the time the out-of-network outpatient mental health care was received on
July 3, 2021, to July 24, 2021. Therefore, we decided that the Plan does not have to waive the deductible for
outpatient mental health care provided by an out-of-network provider from July 3, 2021, to July 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share charged for diabetic orthotics provided on March 10, 2021.
You asked the Plan to waive this cost share. You say that you paid your copayment and should pay nothing else. The Plan denied your request. The Plan says this cost share was charged based on the claim submitted by your provider and the Plan contract agreement.
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 diabetic shoes and inserts. 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 cost share charged for diabetic orthotics provided on March 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator.
You asked the Plan to pre-approve the concentrator. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.
The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify for oxygen solely based on blood gas studies obtained during sleep. To qualify for home oxygen, the patient must meet one of the following blood gas levels: 1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest; 2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during sleep for a patient who have hypoxia symptoms during sleep; 3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for patients who have hypoxia symptoms during exercise; 4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of dependent edema, pulmonary hypertension, or erythrocythemia. For patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90% on room air, there is a rebuttable presumption of non-coverage. 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 concentrator. Our reviewer says that the requested concentrator is not medically reasonable or necessary. Our physician reviewer found the provided medical records do not document any hypoxia which would meet Medicare criteria for coverage of home oxygen therapy. Based on the medical records provided, there is no documentation that the supplemental oxygen meets Medicare criteria to be medically necessary and reasonable. 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 concentrator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy (G0283), office visit (99202) and spinal x-ray (72100) provided on August 11, 2021, through August 16, 2021.
You asked the Plan to pay for the physical therapy, office visit and spinal x-ray. You say that you would like reconsideration because you reviewed your contract and these services should be covered and this is the best provider to manage your condition. The Plan denied your request. The Plan says only manual manipulation of the spine is 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 service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the physical therapy (G0283), office visit (99202) and spinal x-ray (72100) provided on August 11, 2021, through August 16, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve L2-3 and L3-L4 Vertiflex device placement for the enrollee.
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to insufficient evidence of efficacy.
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 surgery. 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. 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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve L2-3 and L3-L4 Vertiflex device placement for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit (G0463) provided on July 13, 2021.
You asked the Plan to waive the copayment for the specialist office visit. You say that the services should be covered, and you cannot afford to pay them. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided.
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 outpatient hospital services, specifically services rendered by a physician specialist in an outpatient hospital setting.
You have been asked to pay a $35 copayment for the outpatient specialist office visit. The record indicates that these services were performed in an outpatient specialist office setting. 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 specialist office visit (G0463) provided on July 13, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 87496, 87498, 87631, 87798, 87486, 87541) provided to the enrollee on August 11, 2020.
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied
your request. The Plan says the services are not supported by the records.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the laboratory services have not been met. CPT code(s): 87496,
87498, 87631, 87798, 87486, 87541, remain not supported. The place of service on the CMS-1500 form line
24B must reflect the location of the patient when the specimen was obtained. The submitted claim form
indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical
documentation and/or claim history indicates that the specimen was obtained in a nursing Facility setting POS
32. Also, the laboratory results submitted indicate the specimen was collected on August 11, 2020, and
received by the lab on August 12, 2020. Of note, the enrollee resides in Georgia (GA) and the billing laboratory
is in Texas (TX); therefore, the billed code cannot be verified. Therefore, we decided that the Plan does not
have to pay for the laboratory services (CPT code(s): 87496, 87498, 87631, 87798, 87486, 87541) provided to
the enrollee on August 11, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for surgical pathology provided on June 29, 2021.
You asked the Plan to waive the deductible for surgical pathology. You say that you should not owe anything for a preventative service. 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. Your contract with the Plan says that there is a $5,100 deductible which applies to colorectal cancer screenings. The record shows that you had not met the $5,100 deductible prior to receiving the services. Therefore, you are responsible to pay the allowed amount of $36.79. The item or service you asked the Plan to waive the deductible for falls within the benefit category colorectal cancer screenings. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $5,100 deductible which applies to colorectal cancer screenings. This cost sharing is a contractual obligation
that had not been met at the time surgical pathology was received on June 29, 2021. Therefore, we decided that the Plan does not have to waive the deductible for surgical pathology provided on June 29, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the extremity study you had on August 11, 2021.
You asked the Plan to waive the copayment for the extremity study. You say that this should be covered with just a $20 copayment. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that because the allowed amount for this service ($99.68) is less than your copayment obligation, you are responsible for the full allowed 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 $160 copayment for radiological diagnostic services. You have been asked to pay a $160 copayment for the extremity study. The extremity study falls within the
radiological diagnostic 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 copayment for the extremity study you had on August 11, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory testing provided on April 29, 2021, billed with codes 82565, 85014, 85018, 85049, 86001, the additional unit of 84520, 82947, 86140, 82040, 83701, 84450, 84460, and five units of 85027.
You asked the Plan to pay for the lab testing as billed. You say that this should be paid. The Plan denied your request. The Plan says after review, multiple codes were approved for payment. However, the remaining denied codes are either not supported by the records, or are billed with a Column 1 code with no appropriate modifier.
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 CPT codes that remain denied are not supported. The file does not contain clear lab results to support these services, not to support the multiple units of many of the billed codes. Based on this information, we decided that Medicare rules for coverage of the lab testing as billed have not been met. Therefore, we
decided that the Plan does not have to pay for the laboratory testing provided on April 29, 2021, billed with codes 82565, 85014, 85018, 85049, 86001, the additional unit of 84520, 82947, 86140, 82040, 83701, 84450, 84460, and five units of 85027
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia for patient of extreme age, younger than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure) (CPT code 99100) and anesthesia complicated by emergency conditions (specify) (List separately in addition to code for primary anesthesia procedure) (CPT code 99140) provided to the enrollee on November 4, 2020.
You asked the Plan to pay for the services. You say that the claim should be paid. 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. CPT code(s): 99100 and 99140, has a status indicator of 'B' on the CMS Physician Relative Value File, and is always bundled into payment for other services not specified and no separate payment is made per Medicare. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia for patient of extreme age, younger than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure) (CPT code 99100) and anesthesia complicated by emergency conditions (specify) (List separately in addition to code for primary anesthesia procedure) (CPT code 99140) provided to the enrollee on November 4, 2020.