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

We decided that the Plan does not have to pay for segmental gradient pressure pneumatic appliance (CPT code E0673-NU-RT and E0673-NU-LT) and pneumatic compression device, high pressure, rapid inflation/deflation cycle, for arterial insufficiency (unilateral or bilateral system) (CPT code E0675RR) provided to the enrollee on July 15, 2021.
You asked the Plan to pay for the DME. You say that the claim should be paid. The Plan denied your request.
The Plan says the services are not covered.
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. The pneumatic compression device and/ or supplies is not covered by
Medicare to prevent deep vein thrombosis during and/or following surgery, at home, or in any setting. The
enrollee used the equipment in the facility during and/or after surgery. Payment for this service would have
been included in the facility DRG or PPS prospective payment. Therefore, we decided that the Plan does not
have to pay for segmental gradient pressure pneumatic appliance (CPT code E0673-NU-RT and E0673-NULT)
and pneumatic compression device, high pressure, rapid inflation/deflation cycle, for arterial insufficiency
(unilateral or bilateral system) (CPT code E0675RR) provided to the enrollee on July 15, 2021
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple (43239) provided July 12, 2021.

You asked the Plan to waive the deductible for the esophagogastroduodenoscopy with biopsy. You say that you feel you have been overcharged for this service. The Plan denied your request. The Plan says the cost for this service was correctly applied to your deductible.

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 a $750 deductible which applies to outpatient hospital services. 

The item or service you asked the Plan to waive the deductible for falls within the benefit category Hospital outpatient facilities and ambulatory surgical centers. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible which applies to Hospital Outpatient Facilities and Ambulatory Surgical Centers. This cost sharing is a contractual obligation that had not been met at the time the esophagogastroduodenoscopy with biopsy was received on July 12, 2021. Therefore, we decided that the Plan
does not have to waive the deductible for the esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple (43239) provided July 12, 2021.

Your complaint about having long calls with unsatisfactory service with the Plan's customer service and potentially having billing issues with the provider is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve vision field assessment tech support for the enrollee.
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 value of this system is not established.
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 services are not considered medically reasonable and necessary in this case. Our physician reviewer found home monitoring of the enrollee's macular degeneration with Foreseehome is not medically necessary in this case. In this case, the enrollee has left exudative macular degeneration, and right intermediate dry macular degeneration. The standard of care in this situation is intravitreal injection with anti-VEGF drugs, and frequent follow-up examinations. The Foreseehome monitoring system has been evaluated and validated by prospective analysis and has been shown to be a safe and effective system for exudative macular degeneration surveillance for high-risk individuals in relatively limited study. In the context of exudative macular degeneration that is being actively treated and closely monitored with examination and imaging, it is not the standard of care for treatment or monitoring. Overall, the Foreseehome system may be more effective than Amsler grid, but only a single study of relatively short duration (1.4 years of mean follow-up) exists to compare the efficacy. There is no evidence that the Foreseehome system improves disease outcomes, or that it would be superior for treatment of the enrollee's intermediate non-exudative macular degeneration as compared with standard treatments. 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 vision field assessment tech support for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Superion interspinous spacer.
You asked the Plan to pre-approve Superion interspinous spacer. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically
necessary.
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 Superion interspinous spacer. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found the enrollee presents with a three-year history of low back and lower
extremity pain. She reports increased pain with sitting, standing and walking. There is reported imaging
evidence of moderate central canal and mild foraminal stenosis at L3/4 and moderate to severe central canal
and at least moderate foraminal stenosis at L4/5. The enrollee is status post L1 kyphoplasty with 25-30%
vertebral body loss. The enrollee has reportedly failed long-term conservative treatment. Current evidence
based medical guideline and peer reviewed literature do not fully support the spinal decompression device
procedure over the 'gold standard' of lumbar laminectomy. There is a lack of large volume, long-term peerreviewed
outcome studies to support the use of this device for this enrollee's medical condition as discussed
above. FDA indications include implantation of the Superion device at one or two adjacent lumbar levels in
enrollees with moderate spinal stenosis in whom operative treatment is indicated at no more than two levels,
from L1 to L5. This enrollee has moderate to severe stenosis at the L4/5 level that not meet FDA indications.
Therefore, the enrollee does not meet criteria for the requested services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Superion interspinous spacer have not been met. Therefore, we decided that the
Plan does not have to pre-approve Superion interspinous spacer.
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 services are necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
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 enrollee does not require the intensity of services provided at an IRF.
Specifically, the enrollee is not shown to be able to perform fifteen hours per week of rehabilitative services
with regular physician evaluation. The enrollee's care needs can be met at a lower level of care.
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 injection services provided on July 9, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the injection services. You say that the services were medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.

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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the services at issue were urgent or emergent. Therefore, we decided that the Plan does not have to pay for the injection services provided on July 9, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan of the pelvis (72192) provided on June 11, 2021.
You asked the Plan to waive the copayment for the CT scan. You say that the services should be covered as you don't feel a co-payment should apply. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 copayment for Outpatient diagnostic tests and therapeutic services and supplies.
You have been asked to pay a $101.41 copayment for a CT scan, which is less than the $275 stated in the
Plan's contract. The record indicates that these services were rendered in an outpatient setting. CT scans fall
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 copayment for a CT scan of the pelvis (72192) provided on June 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the opioid treatment services provided on January 31, 2021.
You asked the Plan to pay for the opioid treatment services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the opioid treatment services provided on January 31, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound services (76700) provided on August 18, 2021.
You asked the Plan to pay for code 76700. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. 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 is a column II code to column I code 93976. 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 the ultrasound services (76700) provided on August 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and panoramic x-ray (D0330) provided on August 30, 2021.

You asked the Plan to pay for the dental services. You say that you had issues with your previous dentist. You say that you thought going to a different dentist would be best. You also say that you do not want to eat through a straw. The Plan denied your request. The Plan says 1 comprehensive oral evaluation is covered every 3 plan years. 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. 

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met. Specifically, the file shows that the frequency limits have been exceeded. The record shows that the Plan paid for a comprehensive oral evaluation and panoramic x-ray that you received on November 6, 2019. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and panoramic x-ray (D0330) provided on August 30, 2021.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve shaving of shoulder bone using an endoscope services identified
with code 28926 and repair of torn tendons of shoulder, open procedure services identified with code 23412.
You asked the Plan to pre-approve shaving of shoulder bone using an endoscope services and repair of torn
tendons of shoulder, open procedure services. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says that the requested services are not medically necessary.
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 shaving of shoulder bone using an
endoscope services and repair of torn tendons of shoulder, open procedure services. Our reviewer says that the
requested items/services are considered medically reasonable and necessary in this case. Our physician
reviewer found the enrollee presents with persistent left shoulder pain and decreased range of motion.
Functional limitations are noted in activities of daily living. Clinical exam findings have been consistent with
imaging evidence of labral tear, rotator cuff tendinosis, long-head biceps tendinosis, and acromioclavicular and
glenohumeral joint osteoarthritis. The enrollee had failed reasonable and/or comprehensive conservative
treatment. Authorization was requested for left shoulder arthroscopy, decompression, and possible mini-open
rotator cuff tear. Evidence based medical literature would support the totality of the surgical request. There is
imaging evidence consistent with rotator cuff tendinosis in the setting of AC joint osteoarthritis and plausible
impingement morphology. MRI findings have not clearly evidenced a rotator cuff tear, but a rotator cuff tear in
this enrollee's clinical scenario may be found at the time of operative evaluation and is supported by clinical
exam findings. Therefore, this request is medically reasonable and necessary for treatment of this 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 shaving of shoulder bone using an endoscope services and repair of torn
tendons of shoulder, open procedure services have been met. Therefore, we decided that the Plan has to preapprove
shaving of shoulder bone using an endoscope services identified with code 28926 and repair of torn
tendons of shoulder, open procedure services identified with code 23412.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (70450) provided September 3, 2021.

You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the code billed has a bundled relationship with another code billed and 
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
radiology services (70450) provided September 3, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for a transthoracic echocardiography provided to the enrollee on August 19, 2021.  You asked the Plan to pay for the echocardiography. You say that this should be paid for. The Plan denied your request. The Plan says payment for this service would be included in the Part A Diagnosis Related Group (DRG) payment to the facility.  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 93312 is "Echocardiography, transesophageal, real-time with image documentation (2D) (with or without M-mode recording); including probe placement, image acquisition, interpretation and report."  We find that CPT code 93312 is not supported in the medical record. Specifically, payment for this code is included in the payment to the facility. Based on this information, we decided that Medicare rules for coverage of the echocardiography have not been met. Therefore, we decided that the Plan does not have to pay for a transthoracic echocardiography provided to the enrollee on August 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on August 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 the enrollee did not have prior authorization for out of network care.

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/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 out of network physician services provided to the enrollee on August 12, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for an X-ray of the chest (71045) provided on August 14, 2021.  

You asked the Plan to pay for an X-ray of the chest. You say that the service at issue was a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met because the request is a duplicate claim.  

The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied.  

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an X-ray of the chest have not been met. Specifically, the Plan has documented that the claim at issue is a duplicate of a prior claim that has been processed and paid. Therefore, we decided that the Plan does not have to pay for an X-ray of the chest (71045) provided on August 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit rendered on June 7, 2021.

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 services are not separately payable.

The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. 

The provider submitted a claim for procedure codes 99213 (office visit) and 93016 (stress test). Code 93016 is a column II code with a modifier indicator of 1 when billed with column I code 99213. Code 93016 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the office visit rendered on June 7, 2021.