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

We decided that the Plan does not have to pre-approve facet joint interventions.
You asked the Plan to pre-approve the facet joint intervention.. You say that the facet joint interventions should be covered. The Plan denied your request. The Plan says the enrollee does not meet coverage criteria for the facet joint intervention.
The Plan follows Medicare rules. Medicare rules say that there rules for the enrollee to meet coverage of the Joint Facet Interventions. Some examples of coverage criteria would be moderate to severe chronic neck or back pain, pain that is present for at least 3 months that does not respond to treatment, absence of untreated radiculopathy or neurogenic claudication, and there is no non-facet pathology per the assessment that could explain the source of the pain. 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 facet joint intervention.. Our reviewer says that the service is not medically necessary. Our physician reviewer found the provider is requesting medial branch blocks (MBBs) (64490RT, 64491RT, 64492RT) for the treatment of cervical spine disease. The medical records submitted did not include any provider notes regarding details of the enrollee's physical examination, history, previous treatments or decision rationale regarding the requested procedures. Under Medicare guidelines, the provider's request is not medically necessary because your records do not support that the enrollee has met the criteria for these procedures. The requested procedure is not medically necessary or reasonable. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the facet joint intervention. have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint interventions.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for inpatient hospital care provided from
November 21, 2020, to November 25, 2020.
You asked the Plan to waive the coinsurance for inpatient hospital care. You say that you disagree with 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 20%
coinsurance for inpatient hospital care.
You received inpatient hospital care from November 21, 2020, to November 25, 2020. Therefore, you are
responsible to pay your share of the cost-sharing charges. The total allowed amount is $6,458.45 and 20% of
that is $1,291.69.
You have been asked to pay the total coinsurance amount of $1,291.69 for inpatient hospital care. Inpatient
hospital care falls 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
coinsurance for inpatient hospital care provided from November 21, 2020, to November 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the crown (D2740) provided on January 7, 2021.
You asked the Plan to reimburse you for the dental service. You say that you were told that your plan increased the reimbursement amount to $700 for 2021. You also say that you were hoping to receive reimbursement for this service. 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 services provided 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 provided 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 crown (D2740) provided on January 7, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a BacTScan (87481, 87500, 87640, 87641, 87653, 87798, 87801) provided on September 30, 2020. You asked the Plan to pay for a BacTScan. You say that this is supported in the records. The Plan denied your request. The Plan says this is not covered for screening purposes.
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 BacTScan, was provided 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 a BacTScan (87481, 87500, 87640, 87641, 87653, 87798, 87801) provided on September 30, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a magnetic resonance angiography (70544) provided on
April 18, 2021.
You asked the Plan to pay for a magnetic resonance angiography. You say that the enrollee had multiple
exams. The Plan denied your request. The Plan says this cannot be separately 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. In this case, we have confirmed that code 70544
has a bundled relationship with code 70553 and cannot be paid as billed. This code cannot be paid as a separate
line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided
that the Plan does not have to pay for a magnetic resonance angiography (70544) provided on April 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided on April 19, 2021.
You asked the Plan to waive the copayment for an office visit. You say that this was your yearly wellness exam and you feel that the charges should be considered fraudulent because of the physician's behavior. 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 $10 copayment for primary care provider visits. The medical records show that you received services beyond an annual wellness exam on April 19, 2021. Therefore, the visit is considered diagnostic, not preventative, and you are responsible to pay the $10 copayment. You have been asked to pay a $10 copayment for an office visit. An office visit falls 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 an office visit provided on April 19, 2021.
We note your complaint that you are unhappy with the physicians behavior. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete upper and lower denture, precision attachments, and replacement of replaceable part of semi-precision or precision attachment provided on March 18, 2021.
You asked the Plan to pay for the complete upper and lower denture, precision attachments, and replacement of replaceable part of semi-precision or precision attachment. You say that one of the representatives stated you would receive 25% to 30% off dentures. You say that the Plan should honor what you were told and pay. The Plan denied your request. The Plan says the services are not covered benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the complete upper and lower denture, precision attachments, and replacement of replaceable part of semi-precision or precision attachment provided on March 18, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on July 23, 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 testing is 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 July 23, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for BluePrint testing (81479) provided on January 7, 2021.
You asked the Plan to pay for BluePrint testing. You say that this was medically necessary. The Plan denied
your request. The Plan says this is not covered.
The Plan must follow Medicare rules. Medicare rules say that MolDX will review all new test/assay clinical
information to determine if a test meets Medicare's reasonable and necessary requirement.
We looked at the file and Medicare rules. MolDX has determined that the test at issue does not meet the
requirements for coverage. Based on this information, we decided that Medicare rules for coverage of
BluePrint testing have not been met. Therefore, we decided that the Plan does not have to pay for BluePrint
testing (81479) provided on January 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a laryngoscopy provided on July 10, 2020.
You asked the Plan to waive the copayment for a laryngoscopy. You say that you are still waiting for the refund from overpayment for the laryngoscopy. 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 $315 copayment for outpatient hospital surgery.
You have been asked to pay $76.53, which is less than the $315 copayment for a laryngoscopy. Laryngoscopies fall within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 laryngoscopy provided on July 10, 2020.
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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a physician who has furnished a consultation or treats an enrollee for a specific medical problem. We looked at the file and Medicare rules. The file does not contain documentation of an established relationship between the enrollee and the ordering provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on October 5, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on August 11, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained for these services. The Plan says that there is no referring provider.
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 physician services provided on August 11, 2020 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.
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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Care at a lower level of care is appropriate in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (00731) provided on February 6, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 00731 has a bundled relationship with code 00813 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the services (00731) provided on February 6, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (76700) provided on May 3, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled
service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 76700
has a bundled relationship with code 93976 and cannot be paid as billed. This code cannot be paid as a separate
line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided
that the Plan does not have to pay for the services (76700) provided on May 3, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for oral surgery services provided on April 2, 2021, by a physician who has opted out of Medicare.
You asked the Plan to pay for oral surgery. You say that the medical services performed were not accurately shown on the claim denial. The Plan denied your request. The Plan says rules for payment have not been met because the provider at issue has opted out of Medicare.
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. Therefore, we decided that the Plan does not have to pay for oral surgery services provided on April 2, 2021, by a physician who has opted out of Medicare.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve components of a computerized prosthetic knee represented by codes L5828, L5845, L5848, and L5856.
You asked the Plan to pre-approve components of a computerized knee. You say that the microprocessor knee is clinically proven to be safer than a mechanical knee and it is medically appropriate that your prosthesis include a microprocessor knee. The Plan denied your request. The Plan says that rules for coverage have not been met because the provided medical records make no mention of you requiring features that are not available with the mechanical knee that has already been approved.
The Plan must follow Medicare rules. Medicare rules say that coverage is extended only if there is sufficient clinical documentation of functional need for the technologic or design feature of a given type of foot. 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 components of a computerized knee. Our reviewer says that the requested items are considered medically reasonable and necessary in this case. Our physician reviewer found that there is documentation that the requested prosthetic components represented by codes L5828, L5845, L5848, and L5856 are medically reasonable and necessary. The enrollee's medical provider, in a note dated July 12, 2021, clearly states you are a K3 level ambulator with need for the microprocessor knee and multi-axial shock absorbing foot to navigate the steep terrain around your house. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage for components of a computerized knee have been met. Therefore, we decided that the Plan has to pre-approve components of a computerized prosthetic knee represented by codes L5828, L5845, L5848, and L5856.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed.
You asked the Plan to pre-approve the bed. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the outpatient hospital services rendered
on April 19, 2021.
You asked the Plan to waive the coinsurance for these services. You say that you feel you received a procedure
and not a surgery. The Plan denied your request. The Plan says the coinsurance 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 20%
coinsurance for Medicare-covered outpatient hospital services.
Review of the file shows that you received outpatient hospital services on April 19, 2021. You have been asked
to pay a 20% coinsurance for these services, for a total of $2,362.00. These services fall within the Medicarecovered
outpatient hospital 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 outpatient hospital services rendered on April 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone replacement graft (D7953) provided on February
19, 2021.
You asked the Plan to pay for the dental service. You say that your dental office advised that the bone
replacement graft was medically necessary. You also say that paying this bill would be a financial hardship for
you. The Plan denied your request. The Plan says bone replacement graft is not listed as a covered service. The
Plan also says that there is no record of you contacting the to verify benefits prior to the date of 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 bone replacement graft is not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the bone replacement graft (D7953) provided on February 19, 2021.