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

 We decided that the Plan does not have to waive the coinsurance for the crutches and knee orthosis provided on June 10, 2021  You asked the Plan to waive the coinsurance for these items. You say that that durable medical equipment should be covered fully. The Plan denied your request. The Plan says that there is a 20% co-insurance for Medicare covered Durable Medical Equipment (DME) and Related Supplies.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Durable Medical Equipment (DME) and Related Supplies.     You have been asked to pay a 20% coinsurance for these items. These items fall within the Durable Medical Equipment (DME) and Related 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 coinsurance for the crutches and knee orthosis provided on June 10, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to reimburse you for the extraction (D7140 x 2), core build up (D2950), bitewing x-rays (D0274), oral exam (D0120), prophylaxis (D1110), bone replacement graft (D7953), and incomplete root canal (D3332) provided from January 22, 2021, to March 25, 2021.  You asked the Plan to reimburse you for the dental services. You say that it is your understanding that the dental reimbursement something extra offered and is not a Medicare service. You also say that you feel if Medicare is not connected to the dental reimbursement, then it should not be a requirement that the provider not be opted out. The Plan denied your request. The Plan says the claim was processed correctly. The Plan also says dental services performed by a dentist that has opted out of Medicare are not payable.  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 Evidence of Coverage clearly states that if you use a provider that has opted out of Medicare you will not receive reimbursement. Therefore, we decided that the Plan does not have to reimburse you for the extraction (D7140 x 2), core build up (D2950), bitewing x-rays (D0274), oral exam (D0120), prophylaxis (D1110), bone replacement graft (D7953), and incomplete root canal (D3332) provided from January 22, 2021, to March 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve CircAid compression wraps for both legs.  

You asked the Plan to pre-approve the compression wraps. You say that if you do not wear your compression wraps, the circulation is bad in your legs and you would like to wear these every day to keep yourself from getting sores/ulcers on your legs. The Plan denied your request. The Plan says the wraps are not covered.  

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the compression wraps have not been met. Compression stockings are excluded from coverage except for those described by codes A6531, A6532, A6534 and A6535. Therefore, we decided that the Plan does not have to pre-approve CircAid compression wraps for both legs.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the manual wheelchair and attachments provided to the enrollee on July 12, 2021.  You asked the Plan to pay for these items. You say that these items were medically necessary. The Plan denied your request. The Plan says that there is no history between the enrollee and prescribing physician.  The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.   The record does not contain valid relevant medical records which support medical necessity for the supplies provided in this case. The records regarding the enrollee's need for a wheelchair are from the DME provider. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the manual wheelchair and attachments provided to the enrollee on July 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve implantable neurostimulator, pulse generator (CPT code L8679), for the enrollee.  You asked the Plan to pre-approve the device. You say that the enrollee has exhausted all attempts of pain relief via medication and pain has gotten progressively worse. The Plan denied your request. The Plan says electroacupuncture is a new agent of unknown use and efficacy in the United States.  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 items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee has chronic pain syndrome, and the provider is planning on employing an auricular electroacupuncture device. There is insufficient literature to demonstrate the safety and efficacy of the requested device for the enrollee's condition. The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. The requested service is not 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 the device have not been met. Therefore, we decided that the Plan does not have to pre-approve implantable neurostimulator, pulse generator (CPT code L8679), for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the cytopathology services coded 88120 provided on April 5, 2021.  

You asked the Plan to pay for the cytopathology 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 a covered benefit.  

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 cytopathology test at issue in this appeal 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 cytopathology services coded 88120 provided on April 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for emergency care provided on April 6, 2021.  You asked the Plan to waive the copayment for emergency care. You say that you were misdiagnosed with allergies when it was shingles. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $120 copayment for emergency care.   You have been asked to pay a $120 copayment for emergency care. Emergency care falls within the emergency 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 emergency care provided on April 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for domiciliary or rest home visit (99336) provided on August 30, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for domiciliary or rest home visit. You say that authorization was not obtained prior to seeing this patient since it is the nursing facilities responsibility to get authorizations for their patients. You also say that it was medically necessary for the patient to receive the treatment and we did not know that the facility failed to get preauthorization for this patient, so you treated this patient anyway. The Plan denied your request. The Plan says this provider is not a network provider with the Plan. The Plan also says that the services were not referred by a network provider or rendered in a participating facility. The Plan also says that they have also determined that these services are not urgent or emergent, nor were they approved in advance.  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 domiciliary or rest home visit (99336) provided on August 30, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to reduce the copayment for cataract surgery provided on June 29, 2021.  You asked the Plan to reduce the copayment for the cataract surgery. You say that an advocate told you that the outpatient surgery copayment was going to be $225. The Plan denied your request. The Plan says the copayment 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 $275 copayment for Medicare-covered surgery or other services provided to you at an ambulatory surgical center, including but not limited to hospital or other facility charges and physician or surgical charges.   You have been asked to pay a $275 copayment for the cataract surgery. Cataract surgery falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to reduce the copayment for cataract surgery provided on June 29, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing 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 were not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of
service (POS) code.
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing
rendered on June 7, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing provided on May 3, 2021.
You asked the Plan to pay for the drug testing. You say that this was medically necessary. The Plan denied your request. The Plan says this was billed with an invalid POS code.
The Plan must follow Medicare rules. Medicare rules say that for lab services, the POS code must reflect the location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. We looked at the file and Medicare rules. The documentation does not indicate this sample was taken by the lab directly. As such, the use of POS code 81 is not supported. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the definitive drug testing provided on May 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services rendered on June 22, 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 01936 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 01936 is anesthesia for percutaneous image guided 
procedures on the spine and spinal cord; therapeutic.

We find that CPT code 01936 is not supported in the medical record. Specifically, the records show that less 
than deep sedation was provided and there is a more appropriate code for these services. Based on this 
information, we decided that Medicare rules for coverage of these services have not been met.

The rules say that payment for codes with a status indicator of B is always bundled into payment for other 
services not specified. 

Billed procedure code 99100 (special anesthesia service) has a status indicator of B and no separate Medicare 
payment. Therefore, we decided that the Plan does not have to pay for the anesthesia services rendered on June 
22, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the neck.
You asked the Plan to pre-approve a CT scan. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 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 a CT scan. Our reviewer says that the service is not medically necessary. Our physician reviewer found there has been no clinical information provided by your doctor to indicate medical necessity. 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 CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the neck.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an alveoloplasty with extractions (D7310), and a replacement
of an attachment (D6091) provided by a participating provider on August 2, 2021.
You asked the Plan to pay for an alveoloplasty with extractions and a replacement of an attachment. You say
that you would like the Plan to pay for this. The Plan denied your request. The Plan says this dental work is not
a covered service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an
alveoloplasty with extractions (D7310), and a replacement of an attachment (D6091) provided by a
participating provider on August 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 
September 1, 2021.

You asked the Plan to pay for the complete series of intraoral x-rays. You say that the provider's office did not 
advise you that your dental plan coverage would not cover the complete series of intraoral x-rays. You also say 
that if you had known, you would have delayed the imaging until December 2021. 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 December 26, 2018 and your complete series of intraoral x-rays (D0210) 
benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the complete series of 
intraoral x-rays (D0210) provided on September 1, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit rendered on June 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 the services are included in the global surgical package.
The Plan must follow Medicare rules. The rules say that same-day services related to the procedure are included in the global surgical package. We looked at the file and Medicare rules. Billed procedure code 99212 (office visit) was billed on the same date as minor surgical procedure 26341 (palmar fascial cord manipulation). The office visit was related to the surgical procedure and payment is included in the global surgical package. Therefore, we decided that the Plan does not have to pay for the office visit rendered on June 24, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance service, basic life support, non-emergency transport (A0428) and ground mileage (A0425) provided August 15, 2021.

You asked the Plan to waive the copayment for the non-emergency ambulance services. You say that you were told there would be no copayment. 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 $250 copayment for Medicare-covered ambulance services. 

You have been asked to pay a $250 copayment for the non-emergency 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, basic life support, non-emergency transport (A0428) and ground mileage (A0425) provided August 15, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing provided on September 24, 2021.

You asked the Plan to pay for the definitive drug testing. You say that this was medically necessary. The Plan denied your request. The Plan says it was decided to pay for the evaluation and presumptive testing. However, the presumptive testing was sufficient with no medical need for the definitive testing as well.

The Plan follows Medicare rules. Medicare rules say that definitive drug testing may be considered medically reasonable and necessary in the treatment of patients with chronic opioid usage when the elements listed in the Medicare rules section are satisfied. 

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 the definitive drug testing. Our reviewer says that the medical necessity criteria for this definitive testing are not met in this case. Our physician reviewer found the enrollee is a 66-year-old male with chronic low back pain. He takes Percocet for pain and recently requested an increase in dosage. He has recently had an epidural steroid injection. There is no indication of diversion or use of drugs of abuse. There was no indication for definitive drug testing. The request was not medically reasonable or 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 definitive drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the definitive drug testing provided on September 24, 2021.
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 you will become bed ridden if you do not get
rehabilitation. The Plan denied your request. The Plan says that you can safely receive the services you need in
other settings. The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay
with an interdisciplinary approach to rehabilitation care. You were admitted for cough, fever, urinary tract
infection after recent hospitalization for coronavirus pneumonia. Your medical problems are stable. There are
no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While you have a
need for physical and/or occupational therapy, there is no documentation of a need for an intensive
rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and
benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found
that your condition does not meet Medicare criteria for IRF 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.