Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided.You asked the Plan to pay for the chiropractic services.The Plan denied your request. The Plan says care must be received from in-network providers and an authorization is required for subsequent Plan chiropractic services.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-approvedcare.The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the chiropractic services.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 chiropractic services provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe intraoral x-ray (D0220), resin-based composite (D2332) and palliative treatment (D9110) provided on June 11, 2020.You asked the Plan to pay forthe intraoral x-ray (D0220), resin-based composite (D2332) and palliative treatment (D9110). You say that you went for emergency treatment and was not aware the services weren't covered.The Plan denied your request. The Plan says the x-ray is limited to once every 12 months and the emergency treatment and resin-based compositeare not covered 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, you also have a maximum benefit of one intraoral x-rayevery 12 months. You received an intraoral x-ray on July 2, 2019, which exhausted your benefit. The resin-based composite (D2332) and palliative treatment (D9110) are not listed as covered benefits.Therefore, we decided that the Plan does not have to pay forthe intraoral x-ray (D0220), resin-based composite (D2332) and palliative treatment (D9110) provided on June 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation provided on March 27, 2020.

You asked the Plan to pay for the limited oral evaluation. You say that you had a toothache and went to the dentist. You say that you paid $840 and thought dental insurance would cover the rest of the cost. The Plan denied your request. The Plan says problem focused exams are covered once every 12 months.

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, you also have a maximum benefit of one problem focused exam every 12 months. You received a limited oral evaluation on March 25, 2020, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation provided on March 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea lift chair.You asked the Plan to pre-approvethe lift chair. You say that you would like reconsideration because you need this lift chair due to pain getting up from the couch because of your condition.The Plan denied your request. The Plan says this is not a Medicare covered benefit.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plan does not have to pre-approvea liftchair.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for CT scans provide.You asked the Plan to waive the copayments for CT scans. You say that you keep receiving more bills and 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 $150 copayment for each radiological diagnostic services.You received CT scans for a total of 2 scans. Therefore, you are responsible to pay a $150 copayment for each CT scan. 

The total amount you owe is: $150 (copayment) x 2 (CT scans) = $300.You have been asked to pay the total copayment amount of $300 for CT scans. CT scans fall 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 copayments for CT scans provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea gingivectomy (D4212).You asked the Plan to pre-approvethe gingivectomy. You say that tooth # 14 needs a crown. You also say that the tooth cannot be restored with a filling.The Plan denied your request. The Plan says gingivectomy is not listed as a covered service. The Plan also says 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. Additionally, the Evidence of Coverage clearly states that any services not listed are not covered.Therefore, we decided that the Plan does not have to pre-approvea gingivectomy (D4212).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ophthalmology visit you had on July 6, 2020.
You asked the Plan to waive the copayment for the ophthalmology visit. You say that you thought all copayments were waived until the end of the year. The Plan denied your request. The Plan says this copayment was charged correctly. The Plan says that the only copayments waived through the end of the year are for primary care visits, outpatient behavioral visits, and telehealth visits.
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 copayment for specialist visits. You have been asked to pay a $40 copayment for the ophthalmology visit. The ophthalmology visit falls within the specialist visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ophthalmology visit you had on July 6, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital services you received from April 22, 2020, to May 4, 2020.
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you have paid $1000 towards this copayment, but you feel the Plan should pay the balance. You say that you believe you met your out-of-pocket maximum. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan states that you had not yet met your out-of-pocket maximum at the time of these inpatient hospital services. You did not meet your out-of-pocket maximum until July 27, 2020, which was after these dates of service.
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 $225 copayment per day for days 1-8 for inpatient hospital services. You have been asked to pay a $225 copayment per day for days 1-8 for the inpatient hospital services. At the time of these services, you had not yet met your out-of-pocket maximum. 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 inpatient hospital services you received from April 22, 2020, to May 4, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab work provided by a participating provider on July 20, 2020.
You asked the Plan to waive the copayment for lab work. You say that you were not told that you would be charged a copayment for this. You say that you thought this was all preventative. The Plan denied your request. The Plan says the correct copayment has been applied.
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 $10 copayment for outpatient diagnostic tests/laboratory tests. You have been asked to pay a $10 copayment for lab work. When additional services are provided during an annual wellness exam, additional copayments are applied; therefore, the correct copayment has been applied. Lab work falls within the outpatient diagnostic tests/laboratory 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 copayment for lab work provided by a participating provider on July 20, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the endoscopy you had on June 4, 2020.
You asked the Plan to waive the copayment for the endoscopy. You say that this endoscopy was necessary so it should be covered. The Plan denied your request. The Plan says the service was covered, however, a copayment applied. In this case, the copayment for the endoscopy is higher than the allowed amount for this service, which is why you were charged the full 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 $395 copayment for outpatient surgery services. You have been asked to pay a $395 copayment for the endoscopy. The endoscopy falls within the outpatient surgery services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the endoscopy you had o June 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

e decided that the Plan does not have to pay forinsertion of an aqueous drainage device (Xen gel implant) provided on September 23, 2019.You asked the Plan to pay forXen gel implant. You say that you are appealing with records.The Plan denied your request. The Plan says the denial of payment for this service is correct, because the documentation does not support coverage of this procedure.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 Xen gel implant. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there are no records demonstrating thatthe enrollee's elevated intraocular pressure was refractory to first and second-line pharmacologic therapies. In addition, the implant was not performed in conjunction with cataract surgery.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Xen gel implant have not been met.Therefore, we decided that the Plan does not have to pay forinsertion of an aqueous drainage device (Xen gel implant) provided on September 23, 2019
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on November 25, 2019.
You asked the Plan to pay for the physician's services. 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
member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all
hospice care from the effective date of election to the date of discharge or revocation. During the election, feefor-service Medicare also covers attending physician services and all care unrelated to the terminal illness until
the first day of the month following the month in which hospice was revoked or discharged.
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 for physician's services provided on November 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence wipes/washcloths.
You asked the Plan to pre-approve incontinence supplies. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested items are not covered.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence wipes/washcloths.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on June 16, 2020. You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The rules say for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. When conducting a review of a covered DME item, ordered by a physician, the contractor shall ensure that the physician saw the beneficiary and conducted a face-to-face assessment. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the durable medical equipment have not been met. Specifically, medical records do not support a prior face-to-face examination with the ordering physician within 6 months of ordering the DME or an appropriate use of telehealth. The submitted consultation notes do not support that a physical examination was performed. The information submitted does not confirm that Medicare coverage criteria have been met. Therefore, we decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on June 16, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on January 2, 2020.
You asked the Plan to waive the copayment for the ER visit. You say that you should not have to pay this copayment because the reason you went to the ER is because of a delay in getting a lancet device. 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 $90 copayment for emergency room services. You have been asked to pay a $90 copayment for the ER visit. This copayment applies regardless of the reason for the ER visit. 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 emergency room (ER) visit you had on January 2, 2020. Please note that this decision only pertains to the ER copayment, not the glucose kit.
Your complaint about the delay in receiving the lancet device is 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvefoot orthotics (L3020 x 2).You asked the Plan to pre-approvethe foot orthotics. You say that you are requesting a reconsideration of the Plan's denial.The Plan denied your request. The Plan says this item is not a covered benefit for your condition.Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.  Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition.Therefore, we decided that the Plan does not have topre-approvefoot orthotics (L3020 x 2).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home visit (99350) provided on July 3, 2019.You asked the Plan to pay forthe home visit. You say that you would like reconsideration because the services rendered were medically necessary.The Plan denied your request. The Plan says the billed code does not appropriate reflect the services provided by the Certified Nursing Assistant.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 99350 is home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A comprehensive interval history; A comprehensive examination;Medical decision making of moderate to high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/orfamily's needs. Usually, the presenting problem(s) are of moderate to high severity. The patient may be unstable or may have developed a significant new problem requiring immediate physician attention. Typically, 60 minutes are spent face-to-face with thepatient and/or family. We find that CPT code 99350 is not supported in the record. Specifically, the record does not support that the physician was present in the beneficiary's home. Based on this information, we decided that Medicare rules for 
coverageof the home visit have not been met.Therefore, we decided that the Plan does not have to pay forthe home visit (99350) provided on July 3, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for eye injection procedures you had on June 2, 2020 and August 4, 2020. You asked the Plan to waive the copayment for the eye injection procedures. You say that these injections shouldn't be considered surgery The Plan denied your request. The Plan says you were charged these copayments correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for outpatient surgical services. You have been asked to pay a $250 copayment for the eye injection procedures. The eye injection procedures fall within the outpatient surgical services benefit category because Medicare considers this type of service to be a surgical 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 eye injection procedures you had on June 2, 2020 and August 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe crown lengthening (D4249).You asked the Plan to pre-approvethe crown lengthening (D4249). You say that the crown lengthening is needed to be able to restore the tooth and prevent gingival inflammation and bone loss.The Plan denied your request. The Plan says the service is not a covered benefit.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coveragerules 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-approvethe crown lengthening (D4249).