Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the indirectly fabricated post and core in addition to a crown (D2952) provided on August 10, 2020.
You asked the Plan to pay for the dental service. You say that you spoke to the plan prior to receiving the services. You say that the crown was approved. You say that you are not working. You say that it is not possible for you to pay this bill. You also say that you are not responsible since the dentist maybe did not apply for that service. The Plan denied your request. The Plan says the post and core in addition to a crown is not listed as a covered service. The Plan also says that any services not listed are not covered.
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 indirectly fabricated post and core in addition to a crown (D2952) provided on August 10, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay forthe acute inpatient hospital care provided from August 3, 2020, to August 6, 2020.You asked the Plan to pay forthe acute inpatient hospital care. The Plan denied your request. The Plan says that inpatient care was not medically necessary.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found that the record showed that at the time of inpatient admission the admitting physician reasonablyexpected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules forcoverage of the acute inpatient hospital care have been met.Therefore, we decided that the Plan has to pay forthe acute inpatient hospital care provided from August 3, 2020, to August 6, 2020.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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe chiropractic services rendered on August 17, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. The provider billed procedure code 97140 (manual therapy techniques). This code is not covered when billed by a chiropractor.Therefore, we decided that the Plan does not have to pay forthe chiropractic services rendered on August 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower denture (D5120).
You asked the Plan to pre-approve the dental items. You say that you need new dentures. You say that you need them to be able to eat properly. You also say that the dentures are medically necessary. The Plan denied your request. The Plan says complete dentures are not listed as covered. The Plan also says that any services not listed are not covered.
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 pre-approve a complete upper denture (D5110) and a complete lower denture (D5120).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe second annual wellness visit (AWV) provided on June 25, 2020.You asked the Plan to pay forthe second AWV. You say that you were not informed by the LifeLine provider that your insurance wouldbe billed for an AWV and you do not believe that they provided this service, since when your PCP does this, they include many more services. You feel that you should have the AWV with your PCP covered as it was more complete, and you were not informed that the prior visit would be billed as such.The Plan denied your request. The Plan says it was decided to make payment in full for the first AWV of the year; however, payment cannot be made for a second AWV.The Plan must follow Medicare rules. Medicare rules say that only one annual AWV is covered. The contract with the Plan limits coverage to once per calendar year. In this case, your Plan is not required to pay for more than one AWV in a calendar year. Although you may have been misinformed by LifeLine, since this is not a network provider with your Plan, your Plan cannot be held liable for this.Therefore, we decided that the Plan does not have to pay forthe second annual wellness visit (AWV) provided on June 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for a portable oxygen concentrator provided.

You asked the Plan to reimburse you for the portable oxygen concentrator. The Plan denied your request. The Plan says the provider is not a contracted provider and not a Medicare approved provider.

The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare program.

We looked at the file and Medicare rules. The file shows that you purchased the portable oxygen concentrator from an online company that is not a provider or a supplier that is enrolled in the Medicare program.Therefore, we decided that the Plan does not have to reimburse you for a portable oxygen concentrator provided.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that this is necessary for the enrollee to
regain her prior level of functioning. The Plan denied your request. The Plan says the enrollee can continue
receiving care at the current hospital.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
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 LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found there is no documentation provided necessitating admission to a LTACH. The
enrollee still requires acute hospital level of care services and is receiving appropriate care at the present acute
care hospital. The enrollee does not require services at the LTACH that are not available at the acute care
hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee
requires that are not available at the health care setting being offered by the health plan. The requested LTACH
services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee
and able to be furnished safely and effectively only on an inpatient basis.
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 LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the crown and inhalation of nitrous oxide/analgesia
provided on October 1, 2020.
You asked the Plan to pay more for the crown and inhalation of nitrous oxide/analgesia. You say that the only
work you had done was x-rays. The Plan denied your request. The Plan says you have exhausted your benefits.
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 Plan offers a maximum plan
benefit coverage amount of $1,000 per year. The contract says that you are responsible for any cost above the
$1,000 maximum. The record shows that you met the annual maximum benefit while processing this claim for
the October 1, 2020, date of service, and your annual maximum benefit has been exhausted. Therefore, we
decided that the Plan does not have to pay more for the crown and inhalation of nitrous oxide/analgesia
provided on October 1, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ambulance transport provided on July 22, 2020.You askedthe Plan to waive the copayment forthe ambulance transport. You say that you were admitted to the hospital overnight and were informed you would not have to pay the ambulance copayment. You say that you are on a fixed income and the bill is a financial hardship.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). Yourcontract with the Plan clearly says that you must pay a $250 copayment for each one-way Medicare-covered ground trip. You have been asked to pay a $250 copayment for the ambulance transport. The ambulance transport 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 forthe ambulance transport provided on July 22, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse the in network rate for the limited oral evaluation (D0140), the periapical x-rays (D0220 x 2), the filling (D2391), the filling (D2392), the oral exam (D0120), prophylaxis (D1110), and the bitewing x-rays (D0274) provided from June 19, 2020, to August 24, 2020.
You asked the Plan to reimburse the in network rate for the dental services. You say that the services should be reimbursed as in network. You say that your daughter and husband use this provider. You say that you depend on them for transportation so it is more feasible that you utilize this provider as well. You also say that you are on a limited income. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says you may be billed more by an out of network provider if the charge is greater than MAC.
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, dental services that you receive out of network may have a higher cost share. The Evidence of Coverage clearly states that you may be billed more by an out of network provider if the charge is greater than MAC. Therefore, we decided that the Plan does not have to reimburse the in network rate for the limited oral evaluation (D0140), the periapical x-rays (D0220 x 2), the filling (D2391), the filling (D2392), the oral exam (D0120), prophylaxis (D1110), and the bitewing x-rays (D0274) provided from June 19, 2020, to August 24, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for ultraviolet (UV) light therapy provided to the enrollee on August 17, 2020.
You asked the Plan to pay for ultraviolet (UV) light therapy provided on August 17, 2020. You say that this treatment was medically necessary. The Plan denied your request. The Plan says that Medicare coverage criteria were not met.
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 pay for UV light therapy provided to the enrollee. Our reviewer says that this service was considered medically reasonable and necessary in this case. Our physician reviewer says UV light therapy is notable as potential therapy for Grover's Disease. References were found that indicate UV therapy can be used for this 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 this service have been met. Therefore, we decided that the Plan has to pay for ultraviolet (UV) light therapy provided to the enrollee on August 17, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the core build up (D2950) for teeth # 4, 6, 11, 19 and 21.
You asked the Plan to pre-approve the dental services. You say that the enrollee has multiple carious lesions, broken teeth, and missing teeth. You say that core build up and crowns are necessary. You also say that the teeth will have good long term prognosis after treatment. The Plan denied your request. The Plan says core build up is not listed as 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 pre-approve the core build up (D2950) for teeth # 4, 6, 11, 19 and 21.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on July 15, 2020.
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 covered.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied. In this case, the MUE for CPT codes 22830 and 22850 is 1. You billed 2 units each of these codes, exceeding the MUE. 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 July 15, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the duplex scan provided on August 10, 2020.

You asked the Plan to waive the copayment for the duplex scan. You say that this was a non-radiological procedure, but it is being billed as radiological. 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 $160 copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in an in-network physician's office or at a freestanding facility. 

You have been asked to pay $112.64, which is less than the standard $160 copayment for the duplex scan. The duplex scan falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. The duplex scan is an ultrasound, which is considered a radiological diagnostic service. 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 duplex scan provided on August 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea partial upper denture (D5213).You asked the Plan to pre-approvethe dental item. You say that you do not have any top teeth. You say that your partial upper denture was misplaced. You say that you are diabetic. You also say that it is difficult to eat without top teeth.The Plan denied your request. The Plan says the partial denture is not medically necessary.Medicare generally does not cover dental services. The Plan follows the same rule.The services you are asking the Plan to pre-approve 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.Therefore, we decided that the Plan does not have to pre-approvea partial upper denture (D5213).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from January 16,
2020, to January 27, 2020.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you contracted E. coli at
the hospital and feel that the provider should be responsible for the charges. 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 $375
copayment for days 1-4 for inpatient hospital care.
You had an inpatient hospital stay from January 16, 2020, to January 27, 2020. Therefore, you are responsible
to pay a $375 copayment for days 1-4 (January 16, 2020, to January 27, 2020). $375 (copayment) x 4 (inpatient
days) = $1,500.
You have been asked to pay the total copayment amount of $1,500 for an inpatient hospital stay. An inpatient
hospital stay falls within the inpatient hospital care benefit category. This means that you have been asked to
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the
copayment for an inpatient hospital stay from January 16, 2020, to January 27, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora colonoscopy provided on July 29, 2020.You asked the Plan to waive the copayment fora colonoscopy. You say that you do not understand why the colonoscopy was not covered.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 $100 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatorysurgical centers. The medical records show that you had polyps removed during a colonoscopy provided on July 29, 2020. Therefore, the colonoscopy is considered diagnostic, not preventative, and you are responsible to pay the $100 copayment. You have been asked to pay a $100 copayment for a colonoscopy. A colonoscopy falls within the outpatient surgery, including 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 waive the copayment fora colonoscopy provided on July 29, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthoracic TLSO provided on June 18, 2020.You asked the Plan to pay forthe orthosis. You say that the orthosis is necessary.The Plan denied your request. The Plan says the orthosis is not supported.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 orthosis have not been met. CPT code L0457, was processed incorrectly since the DME is not supported by referring physician exam. The medical records submitted include an order form, exam notes, a letter explaining the need for the items billed and an invoice with the proof of delivery. However, per review of themember's claim history, there were no claims from the ordering/ referring physician within the last 6 months prior to the date of the service. Therefore, without a face-to-face encounter, the ordering physician couldn't gather the information associated with diagnosing, treating, or managing the clinical condition for which the durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) were ordered.Therefore, we decided that the Plan does not have to pay forthoracic TLSO provided on June 18, 2020