Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible forphysical therapy services received September 9, 2020.You asked the Plan to waive the deductible forphysical therapy services. You say that you did not want to receive the services provided on September 9, 2020,because you believe they were not required.The Plan denied your request. The Plan says the claim processed correctly because you had not met your deductible at the time of service.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is $750 deductible for outpatient rehabilitation services. The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient rehabilitation services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $750 deductible for outpatient rehabilitation services. This cost sharing is a contractual obligation that had not been met at the time physical therapy services were received on September 9, 2020.Therefore, we decided that the Plan does not have to waive the deductible forphysical therapy services received September 9, 2020.Your complaint about receiving a service you did not wantis not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for office visit services provided to the enrollee on June 25,
2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says claims must be filed with the appropriate Medicare claims processing contractor no later than
12months (one calendar year) after the date of service.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010,
must be filed no later than one calendar year after the date of service.
The record shows that a claim for the services was not filed until [enter date the claim was filed]. This means
that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we
decided that the Plan does not have to pay for office visit services provided to the enrollee on June 25, 2020
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on July 13, 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 follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.
The test at issue in this appeal, a respiratory infectious agent detection panel, 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 laboratory services rendered on July 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a walker purchased on February 22, 2020.
You asked the Plan to pay for the walker. You say that you are at home and cannot go to a provider because of
COVID-19. The Plan denied your request. The Plan says Amazon.com is not a Medicare provider.
The Plan must follow Medicare rules. Medicare rules say that services must be provided by providers who are
enrolled in the Medicare program.
Amazon is not a Medicare-eligible provider. Optimum did not pre-approve the walker. We found no exception
that would require Optimum to pay for these items/services. Therefore, we decided that the Plan does not have
to pay for a walker purchased on February 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe periapical x-rays rendered on September 15, 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.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicarecoverage. 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 forthe periapical x-rays rendered on September 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the co payment for the specialist services rendered.

You asked the Plan to waive the co payment for these services. You say that you disagree with the charges.The Plan denied your request. The Plan says the co payment was applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 co payment for in-network provider and professional services in a specialist's office. 

Review of the file shows that you received specialist services on July 9, 2020. You have been asked to pay a $45 co payment for these services. These services fall within the in-network provider and professional services in a specialist's office 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 co payment for the specialist services rendered.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the co payment for the CTA of chest provided.

You asked the Plan to waive the co payment for the chest CTA. You say that you are appealing your cost-share responsibility for the services you received and you were not told you would have a high co payment for the services.The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co payments, deductibles and coinsurance). 

Review of the file show that you received the chest CTA. The Medicare-allowed amount for the diagnostic radiology is less than the set $250 co payment; therefore, you have been asked to pay the lesser amount of $224.26 for the chest CTA. 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 co payment for the CTA of chest provided
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost shares forthe home infusion therapy services provided from October 10, 2020, to October 15, 2020.You asked the Plan to waive the cost shares forthe services provided. You say that the prescription should be covered under Part D.The Plan denied your request. The Plan says the cost share 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 20% of the plan-allowed amount for Medicare Part B prescription drugs. You have been asked to pay 20% of the plan-allowed amount for the services provided. The services fall within the Medicare Part B prescription drugs benefit category. Covered services include drugs you take using durable medical equipment. 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 nothave to waive the cost shares forthe home infusion therapy services provided from October 10, 2020, to October 15, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay forthe initial observation care provided on July 26, 2020.You asked the Plan to pay forthe initial observation care. You say that the enrollee was already a patient in the hospital when services were rendered.The Plan denied your request. The Plan says the enrollee was enrolled in hospice on this date of service.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 initial observation care provided on July 26, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the external transmitter represented by CPT code A9277
provided on June 9, 2020.
You asked the Plan to pay for CPT code A9277. You say that you would like the Plan to reconsider their denial
of payment. The Plan denied your request. The Plan says the external transmitter is not covered by Medicare or
the Plan.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they
are medically reasonable and necessary and replace a blood glucose monitor.
We looked at the file and Medicare rules. The records show that the transmitter you received was billed with
CPT code A9277. This code is for a transmitter that is used with a CGM that is considered non-therapeutic.
Medicare only covers CGMs and supplies that are for use with a CGM that meets the definition of therapeutic.
Therefore, we decided that the Plan does not have to pay for the external transmitter represented by CPT code
A9277 provided on June 9, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the lab services provided on September 2, 2020.
You asked the Plan to waive the copay for the lab services. You say that you were sent for lab work in the same
building as your physician's office. The Plan denied your request. The Plan says the cost share 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 $40
copay for lab services in an outpatient hospital facility.
You have been asked to pay $27.97 for the lab services. Because the amount is less than the $40 copay, you
were charged the lesser amount. The lab services fall within the outpatient diagnostic tests 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 copay for the lab services provided on September 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost shares forthe medical services provided on April 24, 2020.You asked the Plan to waive the cost shares forthe services provided. You say that you should not be billed twice for the same injection.The Plan denied your request. The Plan says the claim was processed 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). You have been asked to pay a 20% coinsurance for Medicare Part B drugs.You were also charged $16.20 for the injection services provided. Because the amount is less than the $20 copay, you were charged the lesser amount. The services fall within the Medicare Part B prescription drugs and physician services benefit categories. 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 cost shares forthe medical services provided on April 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea spinal pain injection for the enrollee.You asked the Plan to pre-approvethe injection. You say thatthis is medically necessary.The Plan denied your request. The Plan says this is not medically necessary.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked ourphysician 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 injection. Our reviewer says that the requested services are not considered medicallyreasonable and necessary in this case. Our physician reviewer found the prior injection did not produce significant pain relief. Therefore, it should not be repeated. The request is 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 injection have not been met.Therefore, we decided that the Plan does not have to pre-approvea spinal pain injection for the enrollee
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvecrowns for tooth #3 and #4.You asked the Planto pre-approvethe crowns. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is not covered for tooth #3 because there are eight points of teeth in biting contact andis not covered for tooth #4 because a prosthetic replacement within fiveyears of insertion is 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. The Plan covers the crowns when the services are medically necessaryand reasonable. 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 crowns. Our physician reviewerfound there is a request for replacement crowns for teeth #3 and #4. The stated reason for replacement isopen margins. The supplied radiographs do not show any compromise of the margins of either tooth. Given the presentation of the case, there is no defect of the seven-year-oldcrown on #3 that is apparent, and no defect around the crown on tooth #4. An open margin that is not decaying is not usually sufficient evidence of the need to replace the crown. A carious lesion at the margin would possibly indicate a need for replacement if it were not in an accessible area that could be restored with a conventional material to repair the crown.  In this instance there is no obvious defect, and no necessity to replace the existing crowns.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the crowns have not been met.Therefore, we decided that the Plandoes not haveto pre-approvecrowns for tooth #3 and #4.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the chemotherapy services provided on
July 16, 2020.
You asked the Plan to waive the coinsurance for the chemotherapy services. You say that you were told before
getting this Plan that these services were covered. You say you cannot afford this amount. 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 Part B drugs, including chemotherapy drugs.
You have been asked to pay a total of $3,143.57 which is 20% of the allowed amount for the chemotherapy
services. The chemotherapy services fall within the "Medicare Part B prescription drugs" 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 chemotherapy services provided on July 16, 2020.
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 it is felt that LTACH is the best option at
this time. The Plan denied your request. The Plan says LTACH is not able to offer superior services compared
to the current facility.
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 the enrollee is a female who was admitted to the hospital due to a kidney infection.
She had a complicated hospital course requiring a procedure and blood pressure and respiratory support. The
infection was severe, with bacteria found in the blood and urine. She begun to improve, and no longer requires
a breathing machine to help her breathe, but he now requires dialysis due to renal failure. She continues to have
a surgical drain in place to collect fluid from around her kidneys. Clinical records dated January 15, 2020,
indicate that he continues to have a significant confusion and are still having problems with eating and will
possibly require a feeding tube.
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.
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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copay forthe ultrasound services provided on August 25, 2020.You asked the Plan to waive the copay forthe services provided. The Plan denied your request. The Plan says the copay was correctly applied to the claim.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 $160 copay for each Medicare-covered radiological diagnostic service, such as ultrasounds. You have been asked to pay $129.36 for the services provided. Because the amount is less than the $160 copay, you were charged the lesser amount. The services fallwithin the outpatient diagnostic tests benefit category. The Plan's cost share waivers due to Covid-19 does not include lab and diagnostic tests. 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 copay forthe ultrasound services provided on August 25, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of the thoracic spine (72157).
You asked the Plan to pre-approve an MRI of the thoracic spine. You say that the services are necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 an MRI of the thoracic spine. Our reviewer says that the services are medically necessary. Our physician reviewer found the instrumented level is not well evaluated on plain x-rays and since the enrollee has increased pain after a procedure on September 11, 2020 an MRI of the thoracic spine is very reasonable especially since there was a pre procedure MRI for comparison. The possibility of a post procedure complication such as infection or hematoma needs to be investigated and an MRI will be the most efficient means to do so. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an MRI of the thoracic spine have been met. Therefore, we decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of the thoracic spine (72157).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrical stimulation therapy rendered.

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 97014 is not covered.

The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid for Medicare purposes. 

We looked at the file and Medicare rules. Billed procedure code 97014 has a status indicator of I and is not valid for Medicare purposes.Therefore, we decided that the Plan does not have to pay for the electrical stimulation therapy rendered.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe periodic oral evaluation, prophylaxis, and bitewing x-rays provided on August 27, 2020 by an OON provider.You asked the Plan to pay forthe periodic oral evaluation, prophylaxis, and bitewing x-rays. You say that you have an interstitial cystitis, and this provider has been accommodating to your medical condition.The Plan denied your request. The Plan says these services were rendered by a non-contracted provider. The Plan also says that prior authorization was not obtained.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 covered when they are received OON.Therefore, we decided that the Plan does not have to pay forthe periodic oral evaluation, prophylaxis, and bitewing x-rays provided on August 27, 2020 by an OON provider.