Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the regadenoson injection you received on February 23, 2021.  You asked the Plan to waive the coinsurance for the regadenoson injection. You say that you assumed that your $40 copayment would be the total charge.  You were not notified that there might be additional charges and you were not given the option to decline those services. The Plan denied your request. The Plan says you were charged this coinsurance correctly.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for Medicare Part B drugs.   You have been asked to pay 20% coinsurance for the regadenoson injection. The regadenoson injection falls within the Medicare Part B drugs benefit category. This is a separately payable item from the procedure itself. 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 regadenoson injection you received on February 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power wheelchair options.
You asked the Plan to pre-approve the requested items. You say that the enrollee's level of function is declining
rapidly. The Plan denied your request. The Plan says coverage criteria have not been met.
The Plan follows Medicare rules. Medicare rules say that power wheelchair options and accessories are only
covered under certain medical indications.
The file shows that elevating leg rests and an expandable control system were requested. 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 requested items.
Our physician reviewer found that per Medicare criteria, the expandable controller (E2377) and harness
(E2313) are not allowed unless there are three power actuators that must be controlled through the joystick, or a
specialty controller is used. No specialty controller has been requested or approved. The enrollee was approved
for only one power option on the wheelchair. Power elevating leg rests are needed if 90-degree flexion is
prevented at the knee, if there is significant lower limb edema, or if the enrollee has a reclining wheelchair. The
documentation does not reveal that this enrollee has an indication for these leg rests.
The file shows that a power seat elevation system and transfer handles were requested. These items are non-
covered because they are not primarily medical in nature. Arm pads were also requested. The rules show that
arm pads are included in the approved power wheelchair. If an option or accessory that is included in another
code is billed separately, the claim line will be denied as not separately payable. A separate request for arm
pads is not necessary.
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 requested items have not been met. Therefore, we decided that the Plan does
not have to pre-approve power wheelchair options.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the pontic (D6245) and retainer crowns (D6740 x2) provided
on April 12, 2021.
You asked the Plan to pay for the pontic and retainer crowns. You say that these services were necessary and
not elective. The Plan denied your request. The Plan says these services are not covered expenses under your
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 the pontic
(D6245) and retainer crowns (D6740 x2) provided on April 12, 2021
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the CardioMEMS 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 this is experimental and not covered.

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 the CardioMEMS device was approved by the Food and Drug Administration (FDA) in 2014 and consists of a sensor device placed in the pulmonary artery to allow measurement of pulmonary artery pressure in the management of patients with congestive heart failure (CHF). The clinical study on which FDA approval was based showed improved clinical outcomes and decreased hospitalizations in patients in whom the CardioMEMS system was implanted, reflecting a patient population with preserved ejection fraction and was somewhat limited in scope. Subsequent follow-up studies remain encouraging and suggest an improvement in heart failure symptoms with the use of the device. In addition, published expert opinion in the cardiology literature is supportive of the clinical usefulness of CardioMEMS.

Nonetheless, there remains a dearth of randomized, blinded clinical studies examining long-term clinical outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the CardioMEMS system would not be considered medically appropriate and necessary in this enrollee's clinical management. 

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 CardioMEMS device for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for a transrectal ultrasound provided to the enrollee on June 2, 2021.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the procedure is inconsistent with the modifier used.

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 76872 is "Ultrasound, transrectal." 

We find that CPT code 76872 is not supported in the medical record. Specifically, this is a diagnostic procedure that requires a professional component modifier. This modifier was not shown in the file. 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 a transrectal ultrasound provided to the enrollee on June 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series of intraoral x-rays (D0210) provided on
August 11, 2021.
You asked the Plan to pay for the complete series of intraoral x-rays. You say that you went to a new dentist
where it was clean. You also say that when you asked the previous dentist to send you your x-rays, they
advised there would be a fee, and you did not want to pay them. The Plan denied your request. The Plan says
this service exceeds the frequency limitation in your benefit 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, complete series of intraoral x-rays
(D0210) is limited to one procedure every three plan years. The record shows that you received a complete
series of intraoral x-rays (D0210) on February 22, 2021 and your complete series of intraoral x-rays (D0210)
benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the complete series of
intraoral x-rays (D0210) provided on August 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prosthetic leg with an advanced foot and ankle feature, and other parts (L5981, L5968).

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says a request for a K3 foot does not meet the Medicare criteria as being reasonable and 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 the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that your functional level and activities require the K3 L5968 or L5981. The physician documentation does not support examples showing that you are a K3 level ambulator. You have multiple significant comorbidities. Furthermore, the therapy notes indicate that you are self-limiting. You state that you feel winded. Your activities do not require a K3 level foot. You have the ability to traverse most environmental barriers and may have vocational, therapeutic, or exercise activity that demands prosthetic utilization beyond simple locomotion. 

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 a prosthetic leg with an advanced foot and ankle feature, and other parts (L5981, L5968).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction (92015), provided on August 13, 2021.
You asked the Plan to pay for the eye refraction. You say that the service should be covered. The Plan denied
your request. The Plan says the benefit has been exhausted.
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 the first routine eye exam each calendar year.
We looked at the file and the Plan's rules. You have exhausted this benefit. Based on this information, we
decided that the Plan's rules for coverage of the eye refraction have not been met. Therefore, we decided that
the Plan does not have to pay for the eye refraction (92015), provided on August 13, 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 18,
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 CPT code.
In this case, the CPT Code Manual definition of code 70450 is computed tomography, head or brain; without
contrast material. We find that CPT code 70450 was billed with code 70496. CPT code 70450 may be eligible
for payment when billed with this code pair. The claim provided in this case does not show that code 70450
was billed with a modifier suitable for payment. Based on this information, we decided that Medicare rules for
coverage have not been met. Therefore, we decided that the Plan does not have to pay for the computed
tomography (CT) scan provided on July 18, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81240, 81241, 81232, 81350, 81283, 81220,
81227, 81230, 81231, 81247, 81291, 81328, 81335, 81355) provided June 3, 2020.
You asked the Plan to pay for the lab services. You say that the lab services were medically necessary. The
Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT code 81240, 81241, 81232, 81350, 81283, 81220, 81227, 81230, 81231, 81247, 81291,
81328, 81335 and 81355 is not supported in the medical record. Specifically, multiple CPT codes were billed
for a single genetic panel. Based on this information, we decided that Medicare rules for coverage of the lab
services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (81240,
81241, 81232, 81350, 81283, 81220, 81227, 81230, 81231, 81247, 81291, 81328, 81335, 81355) provided June
3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on April 19, 2021.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says screening tests are 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 testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab services provided on April 19, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the ground mileage (A0425) and non-emergency ambulance
transport (A0428) provided on January 28, 2021.

You asked the Plan to pay for the ground mileage and non-emergency ambulance transport. You say that the
services rendered were not related to the hospice treatment. You also say that the enrollee received a medically
necessary ambulance transport for hypokalemia. The Plan denied your request. The Plan says Original
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the
enrollee's terminal condition.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services.

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for the ground mileage (A0425) and non-emergency ambulance
transport (A0428) provided on January 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2311, E2313, E2377).
You asked the Plan to pre-approve the additional accessories. You say that this is medically necessary. The Plan denied your request. The Plan says upper limb strength and function are adequate for the member to be able to control the power options using their own switches which are included in the allowance of these power options.
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 additional accessories. Our reviewer says that the requested additional accessories are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not reveal that the enrollee requires other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-proportional input devices (e.g., sip and puff, head array, etc). The enrollee does not need to operate 3 or more powered seating actuators through the drive control, a separate display (i.e., for alternate control devices), other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. The enrollee's function in the upper extremities with the ability to feed and groom herself indicates that the enrollee can control any power options through their own individual switches. 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 additional accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2311, E2313, E2377).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the abdomen x-ray rendered on July 8, 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 procedure code 74018 is 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 74018 (abdomen x-ray, one view) and 74240 (upper gastrointestinal tract x-ray). Code 74018 is a column II code with a modifier indicator of 1 when billed with column I code 74240. Code 74018 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 abdomen x-ray rendered on July 8, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay $5.50 more for the bitewing x-rays, periodontal maintenance, and fluoride varnish provided on July 20, 2021.
You asked the Plan to pay $5.50 more for the bitewing x-rays, periodontal maintenance, and fluoride varnish. You say that you should only owe a $50 copay, a $50 deductible, and half of the $20 balance to be split at $10 each between the Plan and yourself at 50% coinsurance. The Plan denied your request. The Plan says that this claim was processed correctly.
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 bitewing x-rays, periodontal maintenance, and fluoride varnish have been met. The 2021 Evidence of Coverage states that you are responsible for a $50 office visit copay, a 50% coinsurance for individual services, and that a $50 deductible applies. The record shows that you were charged the $50 copayment plus the $50 deductible. There was a remaining $20 for covered services which you were charged $15.50 for. The contract clearly states that you will be responsible for a 50% coinsurance for individual services, meaning you reasonably believed you would only be responsible for half ($10) of the $20 charge. Therefore, we decided that the Plan has to pay $5.50 more for the bitewing x-rays, periodontal maintenance, and fluoride varnish provided on July 20, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says the services can safely be received in other settings.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 admission. Our reviewer says that the requested admission is not medically reasonable or necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the wrist x-ray rendered on May 24, 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 procedure code 73110 is not supported.
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 73110 is radiologic examination, wrist; complete,
minimum of 3 views.
We find that CPT code 73110 is not supported in the medical record. Specifically, there is no codumentation of
a complete x-ray of the wrist with a minimum of three views. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pay for the wrist x-ray rendered on May 24, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on January 9, 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 procedure code 15738 is not supported.
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 15738 is muscle, myocutaneous, or fasciocutaneous flap;
lower extremity.
We find that CPT code 15738 is not supported in the medical record. Specifically, there is no documentation of
a muscle, myocutaneous, or fasciocutaneous flap of the lower extremity. Based on this information, we decided
that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does
not have to pay for the surgical services rendered on January 9, 2021