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

We decided that the Plan does not have to pre-approve a Group 2 standard multi-power option power wheelchair and accessories.
You asked the Plan to pre-approve a power wheelchair with power tilt and recline, power elevating leg rests and associated electronics. You say that the enrollee needs a power wheelchair with power tilt and recline, power elevating leg rests and associated electronics The Plan denied your request. The Plan says the records do not show a history of spasticity or catheterization and there is no evidence of severe leg swelling therefore the options are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 power wheelchair with power tilt and recline, power elevating leg rests and associated electronics. Our reviewer says that the documentation does not support that the criteria in LCD L33792 for the combination power tilt/power recline and power elevating leg rest upgrades have been met. Our physician reviewer found the documentation does not reveal a musculoskeletal condition or the presence of a cast or brace which prevents 90-degree flexion at the knee; or significant edema of the lower extremities that requires an elevating legrest. The physician documentation does not reveal that the patient is at high risk for development of a pressure ulcer. There is no Braden Scale and patient has no current ulcer and now uses a special weight reduction cushion. The patient does not use intermittent catheterization for bladder management and does not need a power seating system to manage increased tone or spasticity. We looked at this physician's review, the file, and Medicare rules. Upgraded electronics are not necessary without the power tilt and recline or elevating leg rest features. Based on this information, we decided that Medicare rules for coverage of a power wheelchair with power tilt and recline, power elevating leg rests and associated electronics have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 2 standard multi-power option power wheelchair and accessories.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the general health panel (CPT code 80050) provided on
March 15, 2021.
You asked the Plan to pay for the general health panel. You say that you were following instructions made by
the provider. The Plan denied your request. The Plan says this service is not covered by the health plan or
Medicare.
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, the general health 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 general health panel (CPT code 80050) provided on March 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (36000) provided on April 5, 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 a status indicator of "B" under the Physician Fee Schedule indicates that payment for covered services are always bundled into payment for other services not specified. We looked at the file and Medicare rules. Code 36000 is assigned a status indicator of "B" under the Physician Fee Schedule, which means that this is a bundled service. Payment for this service is bundled into payment for other services. No separate payment can be made for code 36000. 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 the services (36000) provided on April 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the office visit and diagnostic imaging rendered on April 8, 2021.
You asked the Plan to waive the cost sharing for these services. You say that the charges are too much and you are on a fixed income. The Plan denied your request. The Plan says the cost sharing was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is $500 yearly deductible which applies to your covered medical services, a $40 copayment for services obtained from a specialist, and a $30 copayment for Medicare-covered non-radiological diagnostic services.
The file shows that you received an echocardiogram on April 8, 2021. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $500 yearly deductible which applies to your covered medical services. This cost sharing is a contractual obligation that had not been met at the time these services were
received on April 8, 2021. The Plan applied $333.08 towards your deductible for these services. At this time, your deductible had been met.
The file shows that you received specialist office visit services on April 8, 2021. You have been asked to pay a $40 copayment for these services. These services fall within the services obtained from a specialist benefit category. This cost sharing is a contractual obligation that you agreed to pay when you enrolled with the Plan. This means that you have been asked to pay the correct amount based on the contract with the Plan.
The file shows that you received an electrocardiogram (EKG) on April 8, 2021. Per the contract with the Plan, there is a $30 copayment for Medicare-covered non-radiological diagnostic services. However, the Medicare allowed amount for these services was $21.62. Given that the allowed amount was less than the $30 copayment, you have been asked to pay $21.62 for these services.
The total amount you have been asked to pay for these services is $394.70. This cost sharing is a contractual obligation that you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost sharing for the office visit and diagnostic imaging rendered on April 8, 2021.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve left and right heart catheterization.
You asked the Plan to pre-approve catheter placement in coronary artery(s) for coronary angiography,
including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with
right and left heart catheterization including intraprocedural injection(s) for left ventriculography, when
performed (93460). You say that this procedure is medically necessary. The Plan denied your request. The Plan
says that the clinical information provided does not meet Plan criteria.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it is medically necessary.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve catheter placement in coronary artery(s)
for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging
supervision and interpretation; with right and left heart catheterization including intraprocedural injection(s) for
left ventriculography, when performed (93460). Our reviewer says that the requested services are considered
medically reasonable and necessary in this case. Our physician reviewer found the provided records support the
medical necessity and reasonableness, as defined by Medicare rules, of the requested service for the enrollee's
condition. The elements of the coverage criteria are satisfied. The requested service is 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 catheter placement in coronary artery(s) for coronary angiography, including
intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right and
left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed
(93460) have been met. Therefore, we decided that the Plan has to pre-approve left and right heart
catheterization.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on March 22, 2021.
You asked the Plan to pay for the bitewing x-rays. You say that your plan should cover two oral exams, two cleanings, one dental x-ray, and one fluoride treatment every year. The Plan denied your request. The Plan says this service is not covered by the Plan.
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. The only types of dental x-rays covered under your plan are complete series of intraoral x-rays (D0210) and panoramic x-ray (D0330). Therefore, we decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on March 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve attendant services.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says Medicare does not cover custodial care without another covered skilled nursing or skilled therapy need.
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from trained medical or paramedical staff, is not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Specifically, we find that the services at issue in this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve attendant services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services (D1330) received on April 5, 2021.
You asked the Plan to pay for the services. You say that this is an important step forward as far as your daily
hygiene is considered. The Plan denied your request. The Plan says the service provided is not a covered
benefit under the dental plan.
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 dental
services (D1330) received on April 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral device/appliance provided on May 5, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the oral device/appliance. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the item rendered is not a covered benefit.
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 the oral device/appliance provided on May 5, 2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for the electrocardiogram provided on July 10, 2019.
You asked the Plan to pay for electrocardiogram, routine ECG with at least 12 leads; with interpretation and report (93000). You say that the enrollee was in town and felt she needed to be seen urgently. The Plan denied your request. The Plan says that no necessity for an out-of-network provider situation has been documented.
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis, and pre-approved care. 
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 electrocardiogram, routine ECG with at least 12 leads; with interpretation and report (93000). Our reviewer says that the out-of-area/out-of-network procedure was emergent and urgently needed. Our physician reviewer found the review indicates that the ECG was medically necessary and reasonable as part of the evaluation. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of electrocardiogram, routine ECG with at least 12 leads; with interpretation and report (93000) have been met. Therefore, we decided that the Plan has to pay for the electrocardiogram provided on July 10, 2019.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on December 15, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. 
We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. 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 the drug testing services provided on December 15, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from December 15, 2020, through December 16, 2020.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you are on a fixed income and cannot afford to pay the charges. 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 $325 copayment per day for days 1-5 for inpatient hospital care. You have been asked to pay a $325 copayment for inpatient hospital care. The services at issue 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 inpatient hospital care provided from December 15, 2020, through December 16, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient Telehealth visit services by a clinical
psychologist on February 10, 2021.
You asked the Plan to pay for the outpatient Telehealth visit services by a clinical psychologist. You say that
you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services
provided are not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that payment for clinical psychologist's services is
limited to treatment by practitioners with a Psychology Doctoral degree, Licensed or certified in the State, with
patient consent, and consult with the attending or primary care physician.
We looked at the file and Medicare rules. Review of the file shows that the documentation does not support
that contact with the attending/primary care physician was completed. Based on this information, we decided
that Medicare rules for coverage of the outpatient Telehealth visit services by a clinical psychologist have not
been met. Therefore, we decided that the Plan does not have to pay for the outpatient Telehealth visit services
by a clinical psychologist on February 10, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance service (A0427) and
mileage (A0425), provided on February 27, 2021.
You asked the Plan to waive the copayment for the ambulance services. 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 $250
copayment for ambulance services.
You have been asked to pay a $250 copayment for the ambulance services. This service falls within the
ambulance services benefit category. This means that you have been asked to pay the correct amount based on
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance
service (A0427) and mileage (A0425), provided on February 27, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the incision and drainage services coded 10061 provided on
December 27, 2020.
You asked the Plan to pay for the incision and drainage services. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the
documentation.
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, the CPT Code Manual definition of code 10061 is incision and drainage of abscess (e.g.,
carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia);
complicated or multiple.
We find that CPT code 10061 is not supported in the medical record. Specifically, the documentation submitted
does indicate that incision and drainage of abscess was performed. However, do not indicate that incision and
drainage of abscess (e.g., carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst,
furuncle, or paronychia); complicated or multiple was performed. Based on this information, we decided that
Medicare rules for coverage of the incision and drainage services have not been met. Therefore, we decided
that the Plan does not have to pay for the incision and drainage services coded 10061 provided on December
27, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist services provided by a participating provider on May 18, 2021.
You asked the Plan to waive the copayment for specialist services. You say that you should not have any charges for this. The Plan denied your request. The Plan says the correct copayment has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for physician/practitioner services/specialist. You have been asked to pay a $40 copayment for specialist services. The correct copayment has been applied to the services that were provided. Specialist services fall within the physician/practitioner services/specialist 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 specialist services provided by a participating provider on May 18, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 87481, 87511, 87640, 87641, 87653, 87150, 87798, 87500, 87529, 87651, 87801)provided to the enrollee on January 11, 2021.
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not supported by the records.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. CPT code(s): 87481, 87511, 87640, 87641, 87653, 87150, 87798, 87500, 87529, 87651, 87801, remain not supported. The place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting POS 11. Also, the laboratory results submitted indicate the specimen was collected on January 11, 2021, and received by the lab on January 13, 2021; therefore, the billed code cannot be verified. It is noted multiple attempts were made to obtain additional information from the provider. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services (CPT code(s): 87481, 87511, 87640, 87641, 87653, 87150, 87798, 87500, 87529, 87651, 87801)provided to the enrollee on January 11, 2021.