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

We decided that the Plan does not have to pre-approve a total knee arthroplasty (27447).
You asked the Plan to pre-approve a total knee arthroplasty. You say that this is medically necessary. The Plan
denied your request. The Plan says the enrollee has not had sufficient conservative therapy.
The Plan must follow Medicare rules. Medicare rules say that Total Knee Arthroplasty (TKA) is considered
reasonable and necessary for Advanced Joint disease when the enrollee has been unsuccessful non-surgical
medical management, when appropriate, and attempted for a minimum of 3 months.
We looked at the file and Medicare rules. The record does not show that the enrollee has had 3 months of nonsurgical
medical management. Based on this information, we decided that Medicare rules for coverage of a
total knee arthroplasty have not been met. Therefore, we decided that the Plan does not have to pre-approve a
total knee arthroplasty (27447).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment testing provided on December 21, 2020.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered service.
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 testing. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that there is no medical history provided and no medical conditions listed. Cardiac gene variant testing has limited clinical application at present and is occasionally useful in more rare familial inherited cardiac conditions, none of which are documented. Current AHA/ACC guidelines recommend using clinical risk factor profiles and occasionally radiologic studies (CT calcium scores) for assessing cardiovascular risk and determining individual patient risk factor modification, use of lipid lowering therapies, etc. Cardiac gene variant testing is not currently recommended for general risk stratification. 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 testing have not been met. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment testing provided on December 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services and wound care provided on July 28, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for skilled nursing services and wound care. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician. The Plan says that the referring provider is also out-of-network.
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 skilled nursing services and wound care provided on July 28, 2020 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the ankle-foot orthosis (AFO) and accessories rendered on August 27, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that claims lines billed with codes without a KX, GA or GZ modifier will be rejected as missing information. We looked at the file and Medicare rules. The file shows that the services at issue were not billed with the required modifier(s). Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the ankle-foot orthosis (AFO) and accessories rendered on August 27, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lantus for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says this drug is self-administered.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Lantus for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a nasal procedure (30999) provided on March 20, 2021.
You asked the Plan to pay for a nasal procedure. You say that this was billed correctly. The Plan denied your request. The Plan says this cannot be paid 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. The rules also say that when reporting Not Otherwise Classified (NOC) Codes, field 19 of the claim should have a concise description of an "unlisted procedure code" or a NOC code if one can be given within the confines of this box. Otherwise, an attachment shall be submitted with the claim. In this case, the CPT Code Manual definition of code 30999 is unlisted procedure, nose. We find that CPT code 30999 is not supported in the medical record. Specifically, the claim did not include a description of this procedure in field 19 of the claim. Based on this information, we decided that Medicare rules for coverage of a nasal procedure have not been met. Therefore, we decided that the Plan does not have to pay for a nasal procedure (30999) provided on March 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal exam (D0180) and intraoral x-ray (D0220) provided on April 7, 2021.
You asked the Plan to pay for the dental exam and x-ray. You say that these services were necessary and should be covered. The Plan denied your request. The Plan says you have exceeded the frequency limitations for these services.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan can cover one comprehensive oral exam or comprehensive periodontal exam every three years. The Plan can cover one first intraoral x-ray per year. Though the Plan offers a dental benefit in excess of Medicare coverage, the dental exam and x-ray are requested in a frequency that is not covered under this benefit. Documentation shows that you had a previous comprehensive oral evaluation and first intraoral x-ray on April 6, 2021. These services were paid for by the Plan. Therefore, we decided that the Plan does not have to pay for the comprehensive periodontal exam (D0180) and intraoral x-ray (D0220) provided on April 7, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on September 19, 2020.
You asked the Plan to pay for the laboratory 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.
The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, however, the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regards to the physician's intent that the test be performed prior to services taking place. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on September 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a heavy-duty walker with a seat (E0149 and E0156).
You asked the Plan to pre-approve a heavy-duty walker with a seat. You say that you would like the Plan to
reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet criteria.
The Plan must follow Medicare rules. Medicare rules say that in order for a heavy-duty walker to be covered,
you must weigh more than 300 pounds.
We looked at the file and Medicare rules. In this case, the documentation provided indicates that you weigh
less than 300 pounds. Although the heavy-duty wheelchair might be helpful, you must weigh more than 300
pounds for coverage to be approved. Therefore, we decided that the Plan does not have to pre-approve a heavyduty
walker with a seat (E0149 and E0156).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the application of a short leg cast provided on April 1, 2021.
You asked the Plan to waive the copayment for the application of a short leg cast. You say that the procedure should be considered a post-operative follow-up. 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 $35 copayment for podiatry services. You received the application of a short leg cast on April 1, 2021. Post-operative follow-ups are subject to cost-sharing charges. Therefore, you are responsible to pay the $35 copayment.
You have been asked to pay a $35 copayment for the application of a short leg cast. The application of a short leg cast falls 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 application of a short leg cast provided on April 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for office visits provided from April 23, 2021, to April 30, 2021.
You asked the Plan to waive the copayments for office visits. You say that you were not aware that you would owe a copayment for Coumadin visits. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 copayment for primary care provider visits.
The medical records show that you had office visits on April 23, 2021, and April 30, 2021. Therefore, you are responsible to pay a $20 copayment per each visit. The total amount you owe is: $40. You have been asked to pay the total copayment amount of $40 for office visits. Office visits fall within the physician/practitioner services, including doctor's office visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for office visits provided from April 23, 2021, to April 30, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on May 20, 2021.
You asked the Plan to waive the copayment for ambulance services. You say that there was a lack of communication about the ambulance services and you feel that you should not be responsible for the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for ambulance services. You have been asked to pay a $250 copayment for ambulance services. Ambulance services 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 ambulance services provided on May 20, 2021.
We note your complaint that there was a miscommunication about your need for ambulance services. Your complaint is a grievance that must be answered by the health plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214), therapeutic, prophylactic, or diagnostic injection (96372), and the physician documentation of a face-to-face visit for a durable medical equipment determination performed by a nurse practitioner, physician assistant or clinical nurse specialist (G0454) rendered by the out-of-network (OON) provider on September 18, 2020.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the office visit (99214), therapeutic, prophylactic, or diagnostic injection (96372), and the physician documentation of a face-to-face visit for a durable medical equipment determination performed by a nurse practitioner, physician assistant or clinical nurse specialist (G0454) rendered by the out-of-network (OON) provider on September 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve HiFi socket system.
You asked the Plan to pre-approve HiFi socket system. You say that you feel this item should be covered. The
Plan denied your request. The Plan says the requested item is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that socket systems are only covered for certain
indications.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve HiFi socket system. Our reviewer says
that the documentation does not support that the requested HiFi socket system is medically reasonable or
necessary. Our physician reviewer found you have acquired absence of left leg above knee. The requested HiFi
socket system is not FDA approved and therefore, not proven safe and effective for your condition.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of HiFi socket system have not been met. Therefore, we decided that the Plan does
not have to pre-approve HiFi socket system.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit on December 8,
2020.
You asked the Plan to waive the copayment for a specialist office visit. You say that at a previous visit your
provider left without reading the blood results. You also say you received a phone call with the results at a later
date, so the charges should not have to be paid. The Plan denied your request. The Plan says you have been
charged the correct cost sharing 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 $40
copayment for visits to specialists, including telehealth visits.
You have been asked to pay a $40 copayment for a specialist office visit, which include telehealth services for
diagnosis. Specialist office visits fall within the Physician/Practitioner Services, Including Doctor's office visits
benefit category. This means that you have been asked to pay the correct amount based on your contract with
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a specialist office visit on December 8, 2020.
Your complaint about the provider walking out of the appointment and forgetting to read the results is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on October 5, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services are not covered.
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, a cardiovascular risk assessment panel, was requested solely for screening
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan
does not have to pay for the laboratory services rendered on October 5, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the methadone services (H0020) provided on February 28, 2021, through March 20, 2021.
You asked the Plan to pay for the methadone services. You say that you would like reconsideration because this service has been billed correctly. The Plan denied your request. The Plan says CPT code H0020 is not payable by Medicare.
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 code H0020 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code H0020 has a status indicator of I. This means that CPT code H0020 is not valid for Medicare purposes. Of note, there is a more appropriate CPT code for the services rendered. Based on this information, we decided that Medicare rules for coverage of the methadone services have not been met. Therefore, we decided that the Plan does not have to pay for the methadone services (H0020) provided on February 28, 2021, through March 20, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve the impression and custom preparation of oral surgical splint.
You asked the Plan to pre-approve the impression and custom preparation of oral surgical splint. You say that the new bite guard you received after your crowns does not fit and you are unable to use it. You say that you have been dealing with this for six months with no relief and new bite splints is the first step in starting the recovery process. The Plan denied your request. The Plan says that the service is not covered because the documentation does not show the service is for any of the covered medical reasons.
The Plan must follow Medicare rules. The rules say that Medicare covers treatment for TMJ syndrome only when the condition or symptom is medical in nature. The treatment must also be medically reasonable and 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 the impression and custom preparation of oral surgical splint. Our reviewer says that the criteria for coverage for a dental splint to treat your TMJ dysfunction have been met. Our physician reviewer found that upon receiving new dental crown restorations the appliance did not fit properly. The medical records indicate that you have been treated for arthralgia of bilateral TMJ successfully with a dental orthotic. Our reviewer says that the use of the splint is for treatment of a medical condition, is medically reasonable and necessary and meets the criteria for coverage.
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 impression and custom preparation of oral surgical splint have been met. Therefore, we decided that the Plan has to pre-approve the impression and custom preparation of oral surgical splint.
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.