Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator.
You asked the Plan to pre-approve the ventilator. You say that this is medically necessary. The Plan denied
your request. The Plan says there is a lack of medical necessity.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory
failure due to COPD.
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 ventilator. Our reviewer says that
the requested ventilator is not medically reasonable or necessary. Our physician reviewer found the record
indicates that you have a chronic obstructive pulmonary disease. The record indicates that you use a LIFE 2000
ventilator about eight hours per week but not in set tidal volume mode. The provided record does not indicate
why the bi-level positive airway pressure machine that the plan has indicated is approvable is not appropriate
for your specific condition. 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 the ventilator have not been met. Therefore, we decided that the Plan does not
have to pre-approve a home ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a seat elevator (E2300).

You asked the Plan to pre-approve a seat elevator. You say that the item is medically necessary. The Plan
denied your request. The Plan says the requested item is not medical in nature.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we
decided that the Plan does not have to pre-approve a seat elevator (E2300).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a toggle switch for an expandable controller (K1080)
and a seat elevator (E2300).

You asked the Plan to pre-approve a toggle switch and seat elevator. You say that the items are medically
necessary. The Plan denied your request. The Plan says the requested items are not covered by Medicare or the
Plan.

The Plan must follow Medicare rules. Medicare rules say that code K0108 must not be used for any component
or feature of an expandable controller at the time of initial issue. The reimbursement for any type of complete
expandable controller is included in the allowance for codes E2377/E2376 plus E2313. A power seat elevation
feature (E2300) and power standing feature (E2301) are non-covered because they are not primarily medical in
nature. If a wheelchair has an electrical connection device described by code E2310 or E2311 and if the sole
function of the connection is for a power seat elevation or power standing feature, it will be denied as noncovered

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of a toggle switch and seat elevator. have not been met. Therefore, we decided that the Plan does not
have to pre-approve a toggle switch for an expandable controller (K1080) and a seat elevator (E2300).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on March 19, 2021.

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 as billed.

We looked at the file, the Plan's contract and Medicare rules. If a laboratory assays two or more genes in a patient in parallel, then those two or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so one HCPCS codes must be submitted for the panel. If the laboratory assays genes in serial, then the laboratory must submit claims for genes individually. The order by the treating clinician must reflect whether the treating clinician is ordering a panel or single genes, and additionally, the patient's medical record must reflect that the service billed was reasonable and necessary. 

When more than two codes from this list are submitted for the same beneficiary on the same date of service, the claims processing system will reject every code submitted after the first two services. However, if a lab runs more than two distinct procedural services from this list on a single date of service, then the lab must use the 59 modifier with each additional service billed as an attestation that it is a distinct procedural service. 

In this case, the enrollee had molecular pathology testing on March 19, 2021. Medicare denies coverage when a laboratory assays two or more genes in a patient in parallel. Those two or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so one CPT code must be submitted for the panel. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on March 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a manual wheelchair with tilt in space.
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied your request. The Plan says you reside in a long-term care facility.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home. Records show that the wheelchair is being requested for use in a SNF or hospital. Therefore, we decided that the Plan does not have to pre-approve a manual wheelchair with tilt in space
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Anti-Tremor wrist device.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says there is no scientific literature to support that this device is an effective treatment.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. 

Without any medical records provided with this appeal, it cannot be determined if this device has any reasonable medical purpose. Therefore, we decided that the Plan does not have to pre-approve an Anti-Tremor wrist device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the pneumatic compression device provided on March 9, 2021.

You asked the Plan to pay for the pneumatic compression device (E0676). You say that the physician prescribed the PCD because the enrollee was at high risk for developing deep vein thrombosis. The Plan denied your request. The Plan says the device was used to prevent deep vein thrombosis and payment would have been included in the facility prospective payment.

The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. 

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan.

This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pay for the pneumatic compression device provided on March 9, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on January 11, 2021.

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 as billed.

The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results. 

We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on January 11, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on November 16, 2020.

You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is being done for screening purposes.

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 services at issue in this case were not supported by the medical records. Our physician reviewer found the provided records do not establish the medical necessity or reasonableness of the requested service, as defined by Medicare rules, for the enrollee's specific clinical situation. 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 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 November 16, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy provided on November 18, 2020.

You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that this claim should be paid in full because this was a preventive service. The Plan denied your request. The Plan says you have been asked to pay 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 $390 copayment for the cost of each Medicare-covered visit to an outpatient hospital facility for outpatient surgery. 

You have been asked to pay a $390 copayment for the diagnostic colonoscopy. The diagnostic colonoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows the reason for the visit was a history of colon polyps which makes the colonoscopy diagnostic in nature. 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 diagnostic colonoscopy provided on November 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve resin based composites, crown-porcelain fused to noble metal, post and core in addition to crown, root canal therapy-premolar, and tooth extraction services.

You asked the Plan to pre-approve resin based composites, crown porcelain fused to noble metal, post and core in addition to crown, root canal therapy-premolar, and tooth extraction services. You say that you feel these services should be covered. The Plan denied your request. The Plan says the requested services are not a covered benefit.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve resin based composites, crown-porcelain fused to noble metal, post and core in addition to crown, root canal therapy-premolar, and tooth extraction services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two resin-based composites of two surfaces (D2331 x2), resin-based composite of four or more surfaces (D2335), resin-based composite of three surfaces (D2393), pin retention (D2951), and pulp cap (D3120) provided on March 24, 2021, and March 31, 2021 by an OON provider.

You asked the Plan to pay for the resin-based composites, pin retention, and pulp cap. You say that you do not agree with the Plan's decision. You also say that you are unable to pay for these services. The Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that there were network providers in your area that could have provided 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. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered when they are received OON. The Plan also says that you did not contact the Plan prior to these dates of services to locate a network provider. Therefore, we decided that the Plan does not have to pay for the two resin-based composites of two surfaces (D2331 x2), resin-based composite of four or more surfaces (D2335), resin-based composite of three surfaces (D2393), pin retention (D2951), and pulp cap (D3120) provided on March 24, 2021, and March 31, 2021 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the interrogation device evaluation (93295) provided on April 23, 2021.

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service 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 $50 copayment for a specialist visit. 

You have been asked to pay a $44.52 copayment for the specialist visit provided. This is the Plan's allowed amount for this service which is less than the applicable copayment.

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 interrogation device evaluation (93295) provided on April 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device.
You asked the Plan to pay for a pneumatic compression device. You say that you are appealing with supporting
records. The Plan denied your request. The Plan says this device is not covered by Medicare to prevent deep
vein thrombosis during and/or following surgery.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the
purpose of prevention of venous thromboembolism is a preventive service.
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan.
This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided
that the Plan does not have to pay for a pneumatic compression device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided April 26, 2021.

You asked the Plan to pay for the comprehensive oral evaluation. You say that the services were medically necessary. The Plan denied your request. The Plan says the benefit for this service has been exhausted.

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, coverage for this service is limited to once every three years. A comprehensive oral exam was already covered on April 8, 2021. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided April 26, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing represented by code 81455 provided on January 25, 2021.

You asked the Plan to pay for code 81455. 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 providers must report services correctly. 

We looked at the file and Medicare rules. Medicare says that genetic testing submitted under code 81455 will be denied as not medically necessary as it is unlikely to impact therapeutic decision-making in the clinical management of the enrollee. Therefore, we decided that the Plan does not have to pay for the genetic testing represented by code 81455 provided on January 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital care (99223) provided April 15, 2021.

You asked the Plan to pay for the hospital care. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim is a duplicate and cannot be paid.

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 99223 is not supported in the medical record. Specifically, the claim submitted is a duplicate to claim. Based on this information, we decided that Medicare rules for coverage of the hospital care have not been met. Therefore, we decided that the Plan does not have to pay for hospital care (99223) provided April 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99213) rendered by the out-of-network (OON) provider on April 14, 2021.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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 service at issue in this appeal.

The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the office visit (99213) rendered by the out-of-network (OON) provider on April 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited bilateral noninvasive physiologic studies of upper or lower extremity arteries (93922) rendered by the out-of-network (OON) provider on February 23, 2021.

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 limited bilateral noninvasive physiologic studies of upper or lower extremity arteries (93922) rendered by the out-of-network (OON) provider on February 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a complete mandibular denture (D5120).
You asked the Plan to pre-approve a complete maxillary denture (D5110) and a complete mandibular denture (D5120). You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says you are covered for 1 complete or partial denture every 5 years. You received a complete upper and lower denture with dental codes D5110 and D5120 on October 1, 2020, which is less than 5 years ago.
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 the Plan's rules. The Plan's contract says you are covered for 1 complete or partial denture every 5 years. You received a complete upper and lower denture with dental codes D5110 and D5120 on October 1, 2020, which is less than 5 years ago. Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a complete mandibular denture (D5120).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided for
December 16, 2020.
You asked the Plan to waive the copayment for the emergency room visit. You say that you do not believe you
should have to pay for the emergency room visit. The Plan denied your request. The Plan says you have been
asked to pay 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 $120
copayment for emergency care.
You have been asked to pay a $120 copayment for the emergency room visit. The emergency room visit falls
within the "Emergency 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 the
emergency room visit provided for December 16, 2020