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

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and panoramic x-ray (D0330) provided on September 3, 2021.
You asked the Plan to pay for the dental services. You say that you rarely use your dental benefits. You say that that should be taken into consideration. You say that you feel you should not be liable for the x-ray as this was ordered by the dentist. You also say that you cannot afford to pay this bill as you live on a tight, fixed income. The Plan denied your request. The Plan says 1 limited oral evaluation is covered per plan year. The Plan says that 1 panoramic x-ray is covered every 3 plan years. The Plan also says that these frequency limits have been exceeded.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage and the services are listed as covered, the frequency limits have been exceeded. The record shows that the Plan paid for a limited oral evaluation that you received on July 1, 2021. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) and panoramic x-ray (D0330) provided on September 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0675 and E0673).
You asked the Plan to pay for a pneumatic compression device. You say that the item is medically necessary. 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 and E0673).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for CxBladder testing (0012M) provided on April 28, 2021.
You asked the Plan to pay for CxBladder testing. You say that this should be covered. The Plan denied your request. The Plan says this is not supported in the records.
The Plan must follow Medicare rules. Medicare rules say that in order to be covered, laboratory services must be related to a patient's illness or injury (or symptom or complaint) and ordered by a physician. The rules also say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. We looked at the file and Medicare rules. The submitted documentation does not include a physician order for the testing at issue or relevant medical records demonstrating this was necessary. Based on this information, we decided that Medicare rules for coverage of CxBladder testing have not been met. Therefore, we decided that the Plan does not have to pay for CxBladder testing (0012M) provided on April 28, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the ultrasound (76775), provided on July 30, 2021.
You asked the Plan to waive the cost share for the ultrasound. You say that the services should be covered. The Plan denied your request. The Plan says the cost share 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% per day, per provider, for diagnostic procedures and tests, Deductible may apply. for outpatient diagnostic tests and therapeutic services and supplies. You have been asked to pay a 20% per day, per provider, for diagnostic procedures and tests, Deductible may apply. for the ultrasound. the ultrasound falls within the outpatient diagnostic tests and therapeutic services and supplies 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 cost share for the ultrasound (76775), provided on July 30, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a computed tomography scan (70450) provided on August 16, 2021.
You asked the Plan to pay for a computed tomography scan. You say that the enrollee had multiple exams. The Plan denied your request. The Plan says this is not separately payable.
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 70450 is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to bypass the edit. 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 computed tomography scan (70450) provided on August 16, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided on March 8, 2021, through March 10, 2021.
You asked the Plan to waive the copayment for the inpatient hospital care. You say that the service should be covered. The Plan denied your request. The Plan says the cost share 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 $350 copayment for each day one through five for inpatient hospital care. You have been asked to pay a $350 copayment for each day one through five for the inpatient hospital care. This service 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 copayment for the inpatient hospital care provided on March 8, 2021, through March 10, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional units of psychological/neuropsychological testing.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the total units requested is more than what is normally approved for the requested services.
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 services. Our reviewer says that the requested additional units are not considered medically reasonable and necessary in this case. Our physician reviewer found it is noted that the provider is asking for an excessive amount of the procedure beyond which is approved. The enrollee has shown an impairment in functioning. She has been showing difficulty with memory issues as noted through the testing, based on administration and scoring. Based on a review of the records, the enrollee does not meet the criteria for additional testing beyond which is approved by the typical guidelines, based on the enrollee's clinical history and the documentation presented. 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 pre-approve additional units of psychological/neuropsychological testing
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the nasal application device (A7034), cushion for use on a nasal mask interface, replacement only (A7032), tubing used with a positive airway pressure device (A7037), and the positive airway pressure filter (A7038) rendered by the out-of-network (OON) provider on August 2, 2021.
You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the items 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 items at issue in this appeal. The Plan did not pre-approve the items at issue. We found no exception that would require the Plan to pay for these items. Therefore, we decided that the Plan does not have to pay for the nasal application device (A7034), cushion for use on a nasal mask interface, replacement only (A7032), tubing used with a positive airway pressure device (A7037), and the positive airway pressure filter (A7038) rendered by the out-of-network (OON) provider on August 2, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a computed tomography scan (70450) provided on July 27, 2021.
You asked the Plan to pay for a computed tomography scan. You say that the enrollee had multiple exams. The Plan denied your request. The Plan says this is not separately payable.
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 70450 is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to
bypass the edit. 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 computed tomography scan (70450) provided on July 27, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan provided on July 24, 2021.
You asked the Plan to pay for the CT scan. You say that the enrollee had multiple exams on this date of service. The Plan denied your request. The Plan says an appropriate modifier was not billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. The file shows that CPT code 70480 was billed with code 70450. We looked at the file and the rules. We find that CPT code 70480 may be eligible for payment when billed with this code pair. The claim information does not indicate that the code at issue was billed with a modifier suitable for payment. Based on this information, we decided that Medicare rules for coverage of the CT scan have not been met. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan provided on July 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the Eylea injection you received on July 29, 2021.
You asked the Plan to waive the copayment for the Eylea injection. You say that you are being double charged for this service. The Plan denied your request. The Plan says it has waived the copayment charged for the administration of the drug, but the remaining copayment for the drug itself was charged 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 $15 copayment for Medicare Part B drugs administered by a health care professional.
You have been asked to pay a $15 copayment for the Eylea injection. The Eylea injection falls within the Medicare Part B drugs administered by a health care professional 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 Eylea injection you received on July 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex procedure.
You asked the Plan to pre-approve the Vertiflex procedure. You say that this procedure is medically reasonable
and necessary for the enrollee's condition. The Plan denied your request. The Plan says the requested procedure
is considered experimental/investigational at this time.
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 Vertiflex procedure. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the Vertiflex spacer is experimental. More research is needed to show safety and
efficacy of the device.
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 Vertiflex procedure have not been met. Therefore, we decided that the Plan
does not have to pre-approve the Vertiflex procedure.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says experimental and investigational procedures are not covered by Medicare.
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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental. More research is needed to show safety and efficacy. 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve occupational therapy provided by a participating provider.
You asked the Plan to pre-approve occupational therapy. You say that the additional sessions are medically necessary. The Plan denied your request. The Plan says the have approved two additional sessions.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 occupational therapy. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the additional therapy services are not an appropriate duration and frequency for treatment of the enrollee's medical 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 occupational therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve occupational therapy provided by a participating provider
Appeal type: Home Health
Decision: Unfavorable

We decided the Plan does not have to pay for home health services provided from April 3, 2021, to April 12, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says code 99601 is assigned a status code "I" defined as "Not valid for Medicare purposes".
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The status indicator for this code prevents payments on Medicare claims. Medicare uses another code for reporting of this service. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for home health services provided from April 3, 2021, to April 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the nasal endoscopy services you received in an otolaryngologist's office on July 15, 2021.
You asked the Plan to waive the copayment for the specialist services. You say that this wasn't an office visit, it was a surgical procedure, so you do not believe this copayment applies. The Plan denied your request. The Plan says you were charged this copayment 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 $45 copayment for specialist visits for Medicare-covered services (including surgery services furnished in a physician's office).
You have been asked to pay a $45 copayment for the specialist services. The Evidence of Coverage clearly states that this copayment applies to surgery services furnished in a physician's office. 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 nasal endoscopy services you received in an otolaryngologist's office on July 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction (D7140) for tooth # 11 provided on June 4, 2021.
You asked the Plan to pay for the extraction of tooth # 11. You say that you have $900 for dental services in your account. You say that the services should be paid. The Plan denied your request. The Plan says up to a
$450 allowance for covered comprehensive dental services every quarter is available. The Plan says that any unused amount each quarter will be rolled over to the next quarter. The Plan also says that the available allowance has been exhausted in the processing of this claim.
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 Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the extractions for tooth # 11 have not been met. Specifically, the file shows that the available allowance has been exhausted. The record shows that when the services in this case were processed, there was an available allowance of $1,350 ($450 x 3). The record shows that the Plan paid $472 for dental services received on August 11, 2021, leaving an available allowance of $878 ($1,350 - $472). The record shows that the Plan paid $592 for dental services received on May 14, 2021, and $286 for dental services received on June 4, 2021. $286 + $592 = $878. Therefore, we decided that the Plan does not have to pay for the extraction (D7140) for tooth # 11 provided on June 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the routine vision services provided on August 5, 2020.
You asked the Plan to pay for the routine vision services. You say that the services should be covered. The Plan denied your request. The Plan says the cost share was applied correctly.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services with a 0-20% coinsurance after the deductible. We looked at the file and the Plan's rules. The cost share was applied correctly. Based on this information, we decided that the Plan's rules for coverage of the routine vision services have not been met. Therefore, we decided that the Plan does not have to pay for the routine vision services provided on August 5, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a K3 foot (L5987, L5986).
You asked the Plan to pre-approve a K3 foot. You say that this is medically necessary. The Plan denied your request. The Plan says that the requested codes cannot be approved.
The Plan follows Medicare rules. Medicare rules say that a shank foot system with vertical loading pylon (L5987) is covered for beneficiaries whose functional level is 3 or above. The rules also state that code L5986 describes separate products which provide either a single motion or a combination of motions commonly attributed to the anatomic ankle. The use of these codes can be used to fully describe additional features or functions not found in the prosthetic foot system (L5987). 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 a K3 foot. Our reviewer says that the requested items are medically necessary. Our physician reviewer found the documentation supports that the member has lost significant weight and is a K3 ambulator with needs for an advanced foot to accomplish exercising and activities. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a K3 foot have been met. Therefore, we decided that the Plan has to pre-approve a K3 foot (L5987, L5986).
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.