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

We decided that the Plan does not have to reduce the coinsurance for the catheter provided on January 8, 2020.
You asked the Plan to reduce the coinsurance for the catheter. You say that you have paid a lower cost for the
same item in the past. The Plan denied your request. The Plan says you have been charged the correct cost
sharing 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 20%
coinsurance for durable medical equipment, oxygen/oxygen equipment and related supplies.
You have been asked to pay $48.24 which is 20% of the allowed amount for the catheter. The allowed amount
in $241.20. ($241.20 x 20% = $48.24). The catheter falls 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 reduce the coinsurance for the catheter
provided on January 8, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran inpatient hospital stay provided from October 17, 2019 to October 22, 2019.You asked the Plan to waive the copayment foran inpatient hospital stay. You say that you feel that this stay should be included in a previous stay because you feel that you were discharged too soon.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 $295 copayment each day for days 1-6 for inpatient hospital care. You had an inpatient hospital stay from October 17, 2019 to October 22, 2019. Therefore, you are responsible to pay $1,180, which is less than the total copayment amount. You have been asked to pay a $1,180 copayment for an inpatient hospital stay. An inpatient hospital stay falls within theinpatient 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 foran inpatient hospital stay provided from October 17, 2019 to October 22, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic exercises, manual therapy techniques, and
electrical stimulation provided on December 2, 2019 to January 24, 2020 by an OON provider.
You asked the Plan to pay for the therapeutic exercises, manual therapy techniques, and electrical stimulation.
You say that the enrollee is entitled to all Medicare approved services. You also say that your office, individual
provider, as well as referring provider, are participating providers with Medicare. The Plan denied your request.
The Plan says the treating provider is a non-network provider who does not work with the enrollee's health
plan. The Plan also says that the enrollee was referred by a non-participating provider
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 has network providers
available who can provide 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 the therapeutic exercises, manual therapy
techniques, and electrical stimulation provided on December 2, 2019 to January 24, 2020 by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a urography provided on November 14, 2019.
You asked the Plan to waive the coinsurance for a urography. You say that you disagree with 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 20% coinsurance for each radiological diagnostic service. You had a urography on November 14, 2019. The allowed mount is $194.52 and 20% of that is $39.53. You have been asked to pay the total coinsurance amount of $39.53 for a urography. A urography falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for a urography provided on November 14, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an EGD provided on January 10, 2020.
You asked the Plan to waive the copayment for an EGD. You say that this was a screening colonoscopy and
you should not 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 $250
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory
surgical centers.
The medical records show that you received an EGD on January 10, 2020. Therefore, you are responsible to
pay a $250 copayment.
You have been asked to pay a $250 copayment for an EGD. An EGD 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 for an EGD provided on January 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea lower partial denture with a resin base (D5212).You asked the Plan to pre-approvethe dental item. You say that the enrollee had an incident on April 3, 2020 where she ended up losing her upper denture and lower partial denture. You say that this has resulted in the enrollee losing weight since she is unable to eat without the dentures. You also say that the enrollee needs the lower partial denture so that her upper denture will not move and bite into her front teeth and cause them to break.The Plan denied your request. ThePlan says dentures are covered once every 5 plan years. The Plan also says that the frequency limit has been reached.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 and partial dentures are a covered service, the frequency limit of 1 denture every 5 plan years has been reached. The record showsthat the Plan previously paid for a lower partial denture that you received on August 4, 2017.Therefore, we decided that the Plan does not have to pre-approvea lower partial denture with a resin base (D5212).
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve belatacept.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says that the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that immunosuppressive drugs are covered when specific criteria are met. 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 these services. Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee has had a lung transplant for idiopathic pulmonary fibrosis. He has suffered complications from the usual drugs used to prevent graft rejection. He has developed chronic kidney disease from the calcineurin inhibitor (CNI) therapy, and leukopenia from CellCept. Belatacept is an immunosuppressive drug approved in renal transplantation that has been used successfully in lung transplant patients who have failed CNI therapy. Belatacept is therefore reasonable and medically 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 these services have been met. Therefore, we decided that the Plan has to pre-approve belatacept.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a muscle, myocutaneous, or fasciocutaneous flap (15734)
provided on November 5, 2019.
You asked the Plan to pay for a muscle, myocutaneous, or fasciocutaneous flap. You say that this was a
complicated case and should be paid. The Plan denied your request. The Plan says this code 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 15734 is muscle, myocutaneous, or fasciocutaneous flap;
trunk.
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 muscle, myocutaneous, or fasciocutaneous
flap. Our reviewer says that this code is not supported. Our physician reviewer found the medical records
submitted do not document that a trunk muscle, myocutaneous, or fasciocutaneous flap was performed,
therefore, this code cannot be verified.
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 muscle, myocutaneous, or fasciocutaneous flap have not been met. Therefore,
we decided that the Plan does not have to pay for a muscle, myocutaneous, or fasciocutaneous flap (15734)
provided on November 5, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forlimited oral exam (D0140) provided January 17, 2020.You asked the Plan to pay forthe dental services. You say that under covered benefits, you are covered for oral exams every 6months, 2 times a year. You have not been seen for an oral exam in the past 6 months and feel that this should be covered.The Plan denied your request. The Plan says this service is not covered under the plan 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 requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forlimited oral exam (D0140) provided January 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on
February 24, 2020.
You asked the Plan to waive the copayment for the specialist office visit. You say that you should not be
responsible for the copayment because the catheter removal should be considered a part of the original surgery.
The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $35
copayment for each specialist visit.
You have been asked to pay a $35 copayment for the specialist office visit. The specialist office visit falls
within the "Physician/Practitioner services, including doctor's office visits" benefit category. Please note, there
is no provision in the contract which indicates a copayment would be waived if performed as a follow-up to a
surgical procedure.
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 specialist office visit provided on February 24, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay forthe first 20 sqcm or less of muscle and/or fascia debridement, each additional 20 sq cm of muscle and/or fascia debridement, and domiciliary or rest home visit provided on November 18, 2019.You asked the Plan to pay forthe muscle and/or fascia debridement services and domiciliary or rest home visit. You say that the enrollee's hospice period ended on November 13, 2019.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 forthe first 20 sq cm or less of muscle and/or fascia debridement, each additional 20 sq cm of muscle and/or fascia debridement, and domiciliary or rest home visit provided on November 18, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ER visit provided on December 24, 2019.
You asked the Plan to waive the copayment for an ER visit. You say that you disagree with 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 $120 copayment for emergency care. You have been asked to pay a $120 copayment for an ER visit. An ER visit 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 an ER visit provided on December 24, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a surgical extraction (D7240) for tooth # 17.
You asked the Plan to pre-approve the dental service. You say that the enrollee has been experiencing
discolored blood with puss discharge. You also say that the enrollee has been experiencing drainage issues
which inhibit his speech, eating and preventing him from sleeping. The Plan denied your request. The Plan says
the surgical extraction 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.
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement
of the enrollee's teeth or the structures directly supporting the enrollee's teeth. These are dental services that
are not covered or paid for by Medicare. Though the Plan offers a dental benefit in excess of Medicare
coverage, the requested surgical extraction is not among those covered under this benefit. The Evidence of
Coverage specifically states that only simple extractions or extractions of teeth to prepare the jaw for radiation
treatments of neoplastic cancer disease are covered. Therefore, we decided that the Plan does not have to preapprove
a surgical extraction (D7240) for tooth # 17.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided from May 21, 2019 to August 5, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 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 physician's services provided from May 21, 2019 to August 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for blood glucose measurement (82947) provided on October 14,
2019.
You asked the Plan to pay for the blood glucose measurement. You say that you would like reconsideration
based on the records submitted. The Plan denied your request. The Plan says CPT code 82947 is identified as
part of another procedure that was billed on the same claim without the appropriate modifier.
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 the
blood glucose measurement has a bundled relationship with code 80048 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 blood glucose measurement (82947) provided
on October 14, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe upper GI endoscopy provided on February 6, 2020.You asked the Plan to waive the copayment forthe upper GI endoscopy. You say that when you had a different insurance plan you were not charged for this procedure.The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $325 copayment for each Medicare-covered in-network ambulatory surgical center visit. You have been asked to pay a $325 copayment for the upper GI endoscopy. The upper GI endoscopy 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 forthe upper GI endoscopy provided on February 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the re-treatment of previous root canal therapy (D3348)
for teeth # 3 and 13.
You asked the Plan to pre-approve the dental services. You say that you have an infection in almost all of your
teeth. The Plan denied your request. The Plan says re-treatment of a previous root canal 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 retreatment of previous
root canal therapy is not among those covered under this benefit. Therefore, we decided that the Plan does not
have to pre-approve the re-treatment of previous root canal therapy (D3348) for teeth # 3 and 13.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the oxygen concentrator rental provided on December 22,
2019.
You asked the Plan to pay for the oxygen concentrator rental. You say that the Plan should pay this claim. The
Plan denied your request. The Plan says the enrollee does not meet criteria for medical necessity.
The Plan must follow Medicare rules. The rules say that oxygen is coverable when medically necessary for
patients with significant hypoxemia who meet certain blood gas evidence requirements.
We looked at the file and Medicare rules. There are no current records supporting medical necessity. Based on
this information, we decided that Medicare rules for coverage of the oxygen concentrator rental have not been
met. Therefore, we decided that the Plan does not have to pay for the oxygen concentrator rental provided on
December 22, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from
September 4, 2019 to September 9, 2019.
You asked the Plan to pay for home health services. You say that you would like reconsideration because this
is per visit billing. The Plan denied your request. The Plan says a corrected claim is needed because of the
incorrect type of bill code.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must
be completed for home health care services to be covered.
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that
Medicare rules for completing the claim for home health services have not been met. Specifically, the claim
submitted includes an invalid type of bill code for home health services. Therefore, we decided that the Plan
does not have to pay for the home health services provided to the enrollee from September 4, 2019 to
September 9, 2019.