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

We decided that the Plan does not have to reimburse you for the topical application of fluoride, excluding varnish, (D1208), prophylaxis (D1110), bitewing x-rays (D0274), oral evaluation (D0120), the filling (D2391) for tooth # 21, and the filling (D2330) for tooth # 22 provided from February 17, 2021, to February 22, 2021.
You asked the Plan to reimburse you for the dental services. You say that you do not think it is a problem that the provider does not accept Medicare as you already paid for the services and are asking to be reimbursed. You also say that you were told you could go to any dentist. The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan also says that payment cannot be made for dental services that are performed by a dentist that has opted out of Medicare.
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, dental services performed by a dentist that has opted out of Medicare are not among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for the topical application of fluoride, excluding varnish, (D1208), prophylaxis (D1110), bitewing x-rays (D0274), oral evaluation (D0120), the filling (D2391) for tooth # 21, and the filling (D2330) for tooth # 22 provided from February 17, 2021, to February 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (CPT code 99214) provided to the enrollee on May 5, 2021.
You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider, and the services were not urgent or emergent, nor were they approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the office visit (CPT code 99214) provided to the enrollee on May 5, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) provided on April 15, 2021.

You asked the Plan to pay for the ambulance service. You say that your blood glucose level dropped significantly low. You say that you called 911. You say that the treatment that was provided saved your life. You say that this was an emergency health situation and therefore the charge of $453 should be covered. The Plan denied your request. The Plan says The Medicare ambulance benefit is a transportation benefit and without a transport there is no payable service.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. 

The ambulance company did not provide transport services on April 15, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) provided on April 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MyoPro 2 Motion G robotic arm brace.
You asked the Plan to pre-approve the MyoPro arm brace. You say that this item would be beneficial to allow
use of the dominant arm which has been unable to increase function despite maximal medical therapy. The
Plan denied your request. The Plan says it is not proven that this device improves health outcomes.
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 MyoPro arm brace. Our reviewer
says that the requested item is not considered medically reasonable and necessary in this case. Our physician
reviewer found that at this time, the requested robotic orthosis is not proven to be more beneficial for treatment
of the patient's medical condition/function of hemiparesis after stroke than any available standard therapy such
as conventional treatments for post stroke hemiparesis therapy including constraint induced movement therapy,
conventional muscle strengthening, and Botox for spasticity if needed. The requested device is not reasonable
and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a
malformed body member.
The MyoPro is not known to be effective, based on scientific evidence, professional standards and expert
opinion, in improving health outcomes in stroke patients. The MyoPro is not in widespread use based on
scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the
long-term outcomes for this patient, improve hemiparetic arm function, or be safe for long term use. There is
insufficient evidence in the literature that this device will increase participation in bimanual activities.
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 MyoPro arm brace have not been met. Therefore, we decided that the Plan
does not have to pre-approve the MyoPro 2 Motion G robotic arm brace.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on March 19, 2021.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
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 items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for out of network physician services provided to the enrollee on March 19, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve gastric band removal 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 the records do not show what medications have been tried and failed.

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 the record indicates that the enrollee had a gastric band placed over two years ago. The record indicates that the enrollee has had five months of dysphagia and regurgitation. An esophagram demonstrated no band slippage. No further work-up or evaluation has been performed to determine the etiology of the enrollee's symptoms. The records provided do not document the medical reasonableness or necessity of the requested service. 

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 gastric band removal for the enrollee.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit coded 99285 and the electrocardiogram coded 93010 provided on January 6, 2021.

You asked the Plan to pay for the emergency department visit and the electrocardiogram. 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 supported by the documentation.

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 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 emergency department visit and the electrocardiogram. Our reviewer says that the documentation does not support that billing of codes 99285 and 93010. Our reviewer found the documentation supports a comprehensive history and exam; however, the documentation does not support decision making of high complexity. This means that there is a more appropriate code to be billed for these services rendered. The documentation did not include and interpretation and report; therefore, code 93010 cannot be confirmed as performed. 

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 emergency department visit and the electrocardiogram have not been met. Therefore, we decided that the Plan does not have to pay for the emergency department visit coded 99285 and the electrocardiogram coded 93010 provided on January 6, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing services provided to the enrollee on April 29,
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 this is not medically necessary.
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 pay for the services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the record indicates that the requested test is ConfirmDx. The enrollee underwent a prostate biopsy with
one core revealing atypical small acinar proliferation in one core. The records indicate the test is ordered on all
cores. The record does not indicate that the enrollee is being considered for repeat biopsy.
The provided medical records are insufficient to determine the medical necessity and reasonableness of the
requested service.
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 services have not been met. Therefore, we decided that the Plan does not
have to pay for genetic testing services provided to the enrollee on April 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on February 15, 2021.
You asked the Plan to pay for the dental service. You say that you feel that this claim should be paid in full. You also say that a full mouth and panoramic are the same. The Plan denied your request. The Plan says 1 full mouth or panoramic x-ray is covered every 36 months. The Plan also says that the frequency limit has been exceeded.
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 and panoramic x-ray is listed as covered, the frequency limit has been exceeded. The record shows that full mouth and panoramic x-rays share a frequency limit of once every 36 months. The record also shows that the Plan paid for the full mouth x-ray that you received on the date of service. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on February 15, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on August 31, 2020.
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. 
We find that CPT codes 82274, 82656, 83520, 83631, 87338 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's office (POS 11). 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 laboratory services provided to the enrollee on August 31, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital admission and services provided from December 7, 2020, to December 11, 2020.

You asked the Plan to waive the copayment for the inpatient care. You say that the hospital keeps sending you a bill but you feel the Plan should pay this cost. The Plan denied your request. The Plan says this claim was processed and paid by the Plan. The $1,180 you are being billed is your share of the cost (copayment) for these services.

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 $295 copayment for each of the first five days of an inpatient hospital stay. There is a $0 copayment for additional days.

The provider billed the Plan $18,834 for the hospital services you received from December 7, 2020, to December 11, 2020. You have been asked to pay a $1,180 copayment for four days of inpatient care ($295 per day x 4 days = $1,180). 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 inpatient hospital admission and services provided from December 7, 2020, to December 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for orthotics management and training (97760) pneumatic compressor, non-segmental home model (E0650) segmental gradient pressure pneumatic appliance (E0673) and non-segmental pneumatic appliance (E0666) provided on February 17, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the durable medical equipment services. You say that the enrollee was treated for post-surgical lymphedema, post-surgical edema/inflammation. You disagree with this denial and believe these services were medically necessary. The Plan denied your request. The Plan says enrollee's must receive their
medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for orthotics management and training (97760) pneumatic compressor, non-segmental home model (E0650) segmental gradient pressure pneumatic appliance (E0673) and non-segmental pneumatic appliance (E0666) provided on February 17, 2021 by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for non-emergency ambulance transportation (A0426, A0425) provided on April 3, 2021.
You asked the Plan to waive the copayment for non-emergency ambulance transportation. You say that you cannot afford to pay for the service. 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 $290 copayment for ambulance services. You have been asked to pay a $290 copayment for non-emergency ambulance transportation. The services at issue fall within the ambulance 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 non-emergency ambulance transportation (A0426, A0425) provided on April 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the nail debridement services (11721) provided April 20, 2021.
You asked the Plan to waive the copayment for the nail debridement services. You say that you would like this cost share waived. The Plan denied your request. The Plan says the cost share has processed correctly in this case.
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 $50 copayment for podiatry services. You have been asked to pay a total cost share of $42.92 for the nail debridement services which is less than the required copayment of $50 for podiatry services. These services fall within the podiatry 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 nail debridement services (11721) provided April 20, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing provided on June 4, 2020.
You asked the Plan to pay for the testing services. You say that the testing was ordered to determine if there was a more effective therapy to treat the enrollee's advanced cancer. The Plan denied your request. The Plan says the testing is unlikely to impact therapeutic decision-making.
The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing is only covered under certain medical indications. We looked at the file and the rules. We find that the testing is not supported in the provided records. Specifically, there are insufficient medical records to show that coverage criteria have been met, and the results of the testing at issue are not present in the records. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 testing provided on June 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a standard walker with platform, seat, and brake attachment (E0143, E0154, E0156, E0159)
You asked the Plan to pre-approve the walker. You say that this is medically necessary, as there is difficulty with balance and coordination. The Plan denied your request. The Plan says an upright walker is not a Medicare-covered benefit.
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 walker. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found a standard walker coded with E0143 is not medically necessary, as the documentation does not reveal a mobility limitation that significantly impairs ability to participate in MRADLs in the home. A heavy-duty walker coded with E0147 is not medically necessary, as the documentation does not indicate the inability to use a standard walker due to a severe neurologic disorder, or other condition causing the restricted use of one hand. The documentation does not reveal a complete detailed neuromuscular exam and is not clear that the enrollee would be able to safely use an upright walker. As the E1043 and the E0147 are not medically necessary, the requested accessories are not medically necessary. 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 walker have not been met. Whether the intention was to request E0143 or E0147, either option is not medically reasonable or necessary. Therefore, we decided that the Plan does not have to pre-approve a standard walker with platform, seat, and brake attachment (E0143, E0154, E0156, E0159)