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

We decided that the Plan does not have to pre-approve Botox treatment (J0585).
You asked the Plan to pre-approve the Botox treatment. You say that the enrollee requires this treatment to treat gastroparesis. The Plan denied your request. The Plan says the enrollee does not have a covered indication for receiving Botox treatment.
The Plan must follow Medicare rules. Medicare rules say that there are only specific indications that Botox treatment is covered for. Gastroparesis or pylorospasm are not covered indications per the LCD. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Botox treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve Botox treatment (J0585).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on April 12,
2021.
You asked the Plan to waive the copayment for ambulance services. You say that the services were medically
necessary so you should not owe a copayment. 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 $265
copayment for ambulance services.
You have been asked to pay a $265 copayment for ambulance services. Ambulance services fall 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 ambulance services
provided on April 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the ankle-foot orthosis with plastic modification you received on June 16, 2021.
You asked the Plan to waive the coinsurance for the ankle-foot orthosis. You say that when you picked this item up, you were never told there would be any member liability. You say that this orthosis does not fit and it causes you pain. The Plan denied your request. The Plan says you were charged this coinsurance correctly. The Plan says that the company from which you received this item has offered to adjust it for you if you wish.
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 prosthetic devices and related supplies. You have been asked to pay 20% coinsurance for the ankle-foot orthosis. The ankle-foot orthosis falls within
the prosthetic devices and related supplies benefit category. This coinsurance applies regardless of your satisfaction with the item. In addition, the provider has offered to adjust this item for you. 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 ankle-foot orthosis with plastic modification you received on June 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the endocrinology office visit you had on
April 7, 2021.
You asked the Plan to waive the copayment for the endocrinology visit. You say that you did not see the doctor
on this date. You said that this visit was a follow-up from the visit you had on March 24, 2021. You stated that
during that visit, they installed a 14-day glucose monitor. You returned on April 7, 2021, and the office staff
gave you a prescription and gave you the readings from the monitor. The Plan denied your request. The Plan
says you were charged this copayment correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $35
copayment for services obtained from a specialist, including treatment by a nurse practitioner, physician's
assistant, or other non-physician health care professional in a specialist's office.
You have been asked to pay a $35 copayment for the endocrinology visit. The specialist visit copayment
applies each time you visit a specialist's office, even if you do not physically see the doctor. 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 endocrinology office visit you had on April 7, 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 the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says he requested admission to an IRF does not meet criteria.
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. Our physician reviewer found the enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a biopsy of the mouth vestibule (40808) provided on May
11, 2021, by a physician who has opted out of Medicare.
You asked the Plan to pay for a biopsy of the mouth vestibule. You say that it would have taken at least a
month or more to find an eligible provider. The Plan denied your request. The Plan says rules for payment have
not been met because the provider at issue has opted out of Medicare.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary
for items or services provided directly by a physician or practitioner who has opted out of the program except
in cases involving emergencies or urgently needed care.
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for a biopsy
of the mouth vestibule (40808) provided on May 11, 2021, by a physician who has opted out of Medicare.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on June 15,
2021.
You asked the Plan to waive the copayment for ambulance services. You say that you disagree with the charges
because you were passing out from a broken vertebra in your back that was not diagnosed the day before. 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 $275
copayment for ambulance services.
You have been asked to pay a $275 copayment for ambulance services. Ambulance services fall 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 ambulance services provided on June 15, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a PET-CT scan from the skull base to mid-thigh (78815).
You asked the Plan to pre-approve a PET-CT scan. You say that the requested service is a medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for the requested service have not been met.
The Plan must follow Medicare rules. Medicare rules say that PET 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 PET-CT scan. Our reviewer says that the requested service is not medically reasonable and necessary in this case. Our physician reviewer found that the requested imaging is supported only as clinically indicated. There is no clinical indication at this time as the requests is for the purpose of a surveillance regimen. 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 PET-CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a PET-CT scan from the skull base to mid-thigh (78815).
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 March 5, 2020.
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 must 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 March 5, 2020.
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
February 25, 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 must 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 February 25, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for a provider certification for home health services (G0180) provided on April 22, 2021, by an out-of-network provider.
You asked the Plan to pay for certification for home health services. You say that the requested services were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for out-of-network care have not been met.
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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for a provider certification for home health services (G0180) provided on April 22, 2021, by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and periapical x-ray (D0220) provided on March 15, 2021.
You asked the Plan to pay for the dental services. You say that you called the plan to inquire about your coverage before the services were rendered. You also say that you were told that no prior approval was needed and that you could be treated immediately. The Plan denied your request. The Plan says the services you received are considered to be routine dental services. The Plan says that there are no routine dental benefits offered with the plan. The Plan also says the plan representative advised that your dental coverage was not effective until April 1, 2021.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid
for by Medicare. Additionally, the record shows that the plan representative confirmed that your dental benefit would not be effective until April 1, 2021. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) and periapical x-ray (D0220) provided on March 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206) and to pay more for the periodontal maintenance (D4910) provided on March 26, 2021.
You asked the Plan to pay for the topical application of fluoride varnish or pay more for the periodontal maintenance. You say that the treating provider is in-network. The Plan denied your request. The Plan says the topical application of fluoride varnish is not a covered service. The Plan also says that the claim processed correctly for the periodontal maintenance, and no further amount is due.
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, topical application of fluoride varnish (D1206) is not among those covered under this benefit. The contract clearly states that you are responsible for a $50 deductible, plus a 20% coinsurance for the periodontal maintenance (D4910). Therefore, we decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206) and to pay more for the periodontal maintenance (D4910) provided on March 26, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (70544) provided on July 14, 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 providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70544 has a bundled relationship with code 70551 and cannot be paid as billed. This code cannot be paid as a separate line item. 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 services (70544) provided on July 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis (L1851) with suspension sleeve (L2397) provided on August 27, 2019.
You asked the Plan to pay for a knee orthosis with suspension sleeve. You say that the items at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for the items at issue have not been met.
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 pay for a knee orthosis with suspension sleeve. Our reviewer says that the items at issue are not considered medically reasonable and necessary in this case. Our physician reviewer found that there is no documentation of recent injury to, or recent surgical procedure on, the enrollee's knee, there is insufficient documentation of an appropriate evaluation of the enrollee, and there is insufficient credible objective documentation of joint laxity. The item coded L2397 (sleeve) is not separately payable when the base item is not covered. 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 knee orthosis with suspension sleeve have not been met. Therefore, we decided that the Plan does not have to pay for a knee orthosis (L1851) with suspension sleeve (L2397) provided on August 27, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral exam (D0120), prophylaxis (D1110), and bitewing x-rays (D0274) provided on June 17, 2021.
You asked the Plan to pay for the dental services. You say that you were advised by a plan representative that 50% of your dental care would be reimbursed. You say that you were not notified of any changes in coverage for you benefits in 2021. You also say that the "Summary of Benefits" should be clear and concise for clients without loopholes. The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan also says that payment cannot be made to providers that have opted out of Medicare.
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 record shows that the provider in this case has opted out of Medicare. 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 pay for the oral exam (D0120), prophylaxis (D1110), and bitewing x-rays (D0274) provided on June 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a debridement of nails (11721) provided on May 17, 2021.
You asked the Plan to pay for a debridement of nails. You say that the services at issue were a medical
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan must follow Medicare rules. Medicare rules say that treatment of mycotic nails may be covered under
the exceptions to the routine foot care exclusion. The class findings, or the presence of qualifying systemic
illnesses causing a peripheral neuropathy, must be present.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of a debridement of nails have not been met. Specifically, the case record does not contain
documentation of class findings nor of a qualifying systemic illness. Therefore, we decided that the Plan does
not have to pay for a debridement of nails (11721) provided on May 17, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the rhythm electrocardiogram (EKG) interpretation and report rendered on March 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 93042 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 93042 (rhythm EKG, interpretation and report only) and 93308 (transthoracic echocardiogram). Code 93042 is a column II code with a modifier indicator of 1 when
billed with column I code 93308. Code 93042 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 rhythm electrocardiogram (EKG) interpretation and report rendered on March 24, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on October 13, 2020.
You asked the Plan to pay for lab tests. You say that you discharged your duties and responsibilities to the enrollee and the Plan should reimburse you for medically necessary tests. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because the documentation submitted does not support the Place of Service (POS) code billed on this claim.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). We looked at the file and Medicare rules. The documentation submitted shows that the sample for this testing was taken in an office setting, therefore the POS code 81 - indicating an independent lab setting - is not appropriate for this claim. Based on this information, we decided that Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on October 13, 2020.