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

 We decided that the Plan does not have to pay for a pneumatic compression device (E0675).  You asked the Plan to pay for a pneumatic compression device. You say that the device is necessary to prevent deep vein thrombosis. The Plan denied your request. The Plan says the pneumatic compression 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 (E0676) is a preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement.  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. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0675).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve insertion of amniotic membrane to the eye surface.  You asked the Plan to pre-approve insertion of amniotic membrane to the eye surface. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve insertion of amniotic membrane to the eye surface. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested service is not sufficiently proven in the literature to establish it as safe and effective for the enrollee's condition. The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. The requested service is not 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 insertion of amniotic membrane to the eye surface have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of amniotic membrane to the eye surface.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to preapprove a therapeutic continuous glucose monitor (CGM).  You asked the Plan to preapprove the CGM. You say that you frequently test your insulin, but only administer twice a day. The Plan denied your request. The Plan says you do not meet coverage criteria.  The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.  We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we decided that the Plan does not have to preapprove a therapeutic continuous glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), prophylaxis (D1110), and intraoral-radiographic images (D0210) provided by an out-of-network provider on January 20, 2021.  You asked the Plan to pay for a comprehensive oral evaluation, prophylaxis, and intraoral-radiographic images. You say that you were unaware that the dentist had opted out of Medicare. The Plan denied your request. The Plan says the rendering dentist has opted out of Medicare; therefore, these services have been correctly denied.  The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.  The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. The rendering dentist has opted out of Medicare effective November 16, 2018, to November 16, 2022. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), prophylaxis (D1110), and intraoral-radiographic images (D0210) provided by an out-of-network provider on January 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a protective outer surface covering system (L5962).  You asked the Plan to pre-approve the protective covering. You say that the protective cover is necessary. The Plan denied your request. The Plan says the enrollee is not exposed to a unusually harsh environment.  The Plan must follow Medicare rules. Medicare rules say that an L5962 protective covering is for enrollee's who require a cover for unusually harsh environments. The notes do not show that the member has special needs for protection against unusually harsh environmental situations.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the protective covering have not been met. Therefore, we decided that the Plan does not have to pre-approve a protective outer surface covering system (L5962).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for the pacemaker evaluations you had during cardiology visits on May 18, 2021, and August 24, 2021.  You asked the Plan to waive the copayments for the pacemaker evaluations. You say that you should only have to pay your office visit copayment for these dates.  You state that the only reason you went to the cardiologist was to have your pacemaker checked. The Plan denied your request. The Plan says you were charged these copayments correctly.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 copayment for outpatient diagnostic procedures and tests.   You have been asked to pay a $35 copayment for the pacemaker evaluations. According to the medical records from these visits, you had physician evaluations AND pacemaker checks on both dates.  Plans are permitted to charge separate cost sharing for diagnostic tests you receive during an office visit. The pacemaker evaluations fall within the outpatient diagnostic procedures and tests 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 the pacemaker evaluations you had during cardiology visits on May 18, 2021, and August 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a comprehensive periodontal evaluation (D0180) provided by a participating provider on June 21, 2021.  You asked the Plan to pay for a comprehensive periodontal evaluation. You say that you believe the Plan should pay for this. The Plan denied your request. The Plan says D0180 is 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 pay for a comprehensive periodontal evaluation (D0180) provided by a participating provider on June 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to reimburse you for the treatment of a root canal obstruction (D3331) provided on August 9, 2021.  You asked the Plan to reimburse you for the dental service. You say that the root canal was approved. You say that on the same day the dentist advised that an obstruction procedure needed to be done first. You say that you were in so much pain you had no choice but to proceed. You also say that this was medically necessary. The Plan denied your request. The Plan says the treatment of a root canal obstruction 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 treatment of a root canal obstruction is not among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for the treatment of a root canal obstruction (D3331) provided on August 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids provided on June 7, 2021.

You asked the Plan to pay for hearing aids. The Plan denied your request. The Plan says the Plan does not cover hearing aids purchased out-of-network.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when purchased from any network hearing aid provider. 

We looked at the file and the Plan's rules. The file shows that the hearing aids were not purchased from a network hearing aid provider. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids provided on June 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the magnetic resonance imaging (MRIs) services you had on June 18, 2021, and July 23, 2021.  You asked the Plan to waive the coinsurance for the two MRIs. You say that you have never paid a bill like this before and you are retired and your social security has not increased. The Plan denied your request. The Plan says you were charged this coinsurance 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 20% coinsurance up to $75 per day for diagnostic radiology services.   You have been asked to pay 20% coinsurance for the two MRIs. The two MRIs fall within the diagnostic radiology 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 coinsurance for the magnetic resonance imaging (MRIs) services you had on June 18, 2021, and July 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory testing provided on November 3, 2020.  You asked the Plan to pay for lab tests. You say that the specimen is collected at physician's office and sent to the lab for processing, so you do not have access to enrollee demographics, limitations, or conditions. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because the documentation submitted does not support the Place of Service (POS) code billed on this claim.  The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS).   We looked at the file and Medicare rules. The documentation submitted shows that the sample for this testing was taken in an office setting, therefore the POS code 81 - indicating an independent lab setting - is not appropriate for this claim. Based on this information, we decided that Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on November 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Neuromuscular Electrical Stimulation (NMES).  You asked the Plan to pre-approve the NMES. You say that the NMES is medically necessary and the original review has missed crucial parts of the medical records. The Plan denied your request. The Plan says the enrollee does not meet coverage criteria.  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 NMES. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found records do not document a spinal cord injury or any of the criteria required in the National Coverage Determination.  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 NMES have not been met. Therefore, we decided that the Plan does not have to pre-approve Neuromuscular Electrical Stimulation (NMES).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided from February 1, 2021, through February 3, 2021.

You asked the Plan to pay for the self-administered drugs. You say that there was a large blood clot preventing the catheter from being inserted so they kept trying with no success. You say that nothing relieved your comfort, and the denial should be reconsidered. The Plan denied your request. The Plan says self-administered drugs in a hospital outpatient setting are not covered by Medicare Part B.

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 pay for the self-administered drugs provided from February 1, 2021, through February 3, 2021.

Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for emergency room services provided on June 29, 2021.  You asked the Plan to waive the copayment for emergency room services. You say that you cannot afford the copayment. The Plan denied your request. The Plan says you were 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 $120 copayment for Medicare-covered emergency room visits.   You have been asked to pay a $120 copayment for Medicare-covered emergency room visits. 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 emergency room services provided on June 29, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for psychotherapy services (90834) provided on June 17, 2021.  You asked the Plan to pay for psychotherapy services. You say that the services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.  The Plan must follow Medicare rules. Medicare rules say that the CP will attempt to consult with the enrollee's attending or primary care physician.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of psychotherapy services have not been met. Specifically, the provided records do not document an attempt to consult with, nor a referral from, the enrollee's attending or primary care physician. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90834) provided on June 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for special anesthesia service (99100) provided on March 9, 2021.  You asked the Plan to pay for anesthesia. You say that you are appealing with a copy of the outstanding claim and related documentation. The Plan denied your request. The Plan says the denial of payment for this service is correct, because code 99100 is always bundled for payment and is not separately payable.  The Plan must follow Medicare rules. Medicare rules say that code 99100 is always bundled into payment for other services. If this service is covered, payment for it is subsumed by the payment for services to which it is incident.  We looked at the file and Medicare rules. This code is always bundled for payment and is not separately payable. Based on this information, we decided that Medicare rules for coverage of anesthesia have not been met. Therefore, we decided that the Plan does not have to pay for special anesthesia service (99100) provided on March 9, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from June 6, 2021, through June 8, 2021.

You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says that the inpatient care is not medically necessary.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 

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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found that the medical record showed that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier emergency department and/or observation care) would span two midnights. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from June 6, 2021, through June 8, 2021.

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: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the inpatient hospital admission and services received May 20, 2021, to May 28, 2021.  You asked the Plan to waive the copayment for the inpatient hospital services. You say that you cannot afford the high cost of the copayment. 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 $300 copayment for Inpatient hospital care.   You have been asked to pay a total of $1,800 ($300 copayment x 6 days = $1,800) for the inpatient hospital services. The inpatient hospital services fall within the Inpatient hospital 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 inpatient hospital admission and services received May 20, 2021, to May 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to reimburse you for the complete series x-ray, image capture only, (D0709) provided on February 16, 2021.  You asked the Plan to reimburse you for the dental service. You say that you were told that your insurance does not cover cleanings. You say that you had to pay $110. You say that this was a regular cleaning as you were scheduled for a deep cleaning the following week. You also say that you should be reimbursed for this service. The Plan denied your request. The Plan says the complete series x-ray, image capture only, is not listed as a covered service. The Plan also says that you signed a treatment plan prior to receiving the service, accepting financial responsibility for this 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 record shows that the $110 payment was for a complete series x-ray, image capture only. The complete series x-ray, image capture only, is not among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for the complete series x-ray, image capture only, (D0709) provided on February 16, 2021.