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

We decided that the Plan does not have to pay for the lumbar sacral orthosis provided to the enrollee on December 9, 2019.
You asked the Plan to pay for the orthosis. The Plan denied your request. The Plan says that the billed service cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for the lumbar sacral orthosis provided to the enrollee on December 9, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from
January 18, 2020 to January 30, 2020.
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you should not be
responsible for the copayment. 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 $275
copayment per day for day(s) 1 to 4 and a $0 copayment each day for day(s) 5 to 90 for a Medicare-covered
stay at a network hospital.
You have been asked to pay a $1,100 copayment for the inpatient hospital stay. ($275 x 4 days = $1,100). The
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 the inpatient hospital stay provided from January 18, 2020 to January 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on December 10, 2019.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, however, the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regards to the physician's intent that the test be performed prior to services taking place. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on December 10, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for pathology services (88363) provided October 1, 2019.
You asked the Plan to pay for the pathology services. You say that services were medically necessary. The Plan denied your request. The Plan says the claim was submitted with an incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 88363 is not supported in the medical record. Specifically, the claim was billed with an Outpatient place of service, however the service was rendered while the enrollee was an inpatient. Based on this information, we decided that Medicare rules for coverage of the pathology services have not been met. Therefore, we decided that the Plan does not have to pay for pathology services (88363) provided October 1, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the Cervical Spine, Thoracic Spine, Lumbar Spine, and Pelvis.
You asked the Plan to pre-approve the MRI. You say that the medical records provided support the need for the requested. The appellant says that the enrollee received a PET scan and the results were abnormal with the need for additional imaging of the spine. The Plan denied your request. The Plan says it is unclear why, in light of the PET scan, all of the spine imaging requests are medically necessary.
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 the MRI. Our reviewer says that the requested MRI services are not medically necessary. Our physician reviewer found the enrollee was newly diagnosed with multiple myeloma. The enrollee underwent a skeletal survey on April 22, 2020 and a PET Scan on May 15, 2020. In a study prospectively comparing PET/CT versus MRI of the spine and pelvis versus skeletal survey, PET/CT was superior to skeletal survey for the detection of bone lesions and was able to detect bone changes in sites out of the MRI field in one-third of patients. The enrollee has already had advanced imaging in the form of a PET scan. Documentation does not support treatment has commenced. The medical necessity for additional MRI testing has not been determined. 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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the Cervical Spine, Thoracic Spine, Lumbar Spine, and Pelvis.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on
December 1, 2019.
You asked the Plan to waive the copayment for the emergency room visit. You say that the service should be
paid for by the plan because it was an emergency service. 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 $90
copayment for emergency care.
You have been asked to pay a $90 copayment for the emergency room visit. The emergency room 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 the
emergency room visit provided on December 1, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prefabricated stainless steel crown (D2931) provided on
March 4, 2020.
You asked the Plan to pay for the crown. You say that you are supposed to have 100% coverage. You also say
that the crown you got used to be the only kind the Plan paid for. The Plan denied your request. The Plan says
this service is not covered under the Plan.
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
prefabricated stainless steel crown (D2931) provided on March 4, 2020.
Your complaint about being dissatisfied with the Plan 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: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ER visit provided on February 3, 2020.
You asked the Plan to waive the copayment for an ER visit. You say that you had an inpatient hospital stay prior to the ER visit and feel that the ER visit should be included in the previous hospital stay. 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 $90 copayment for emergency care. The medical records show that you had an ER visit on February 3, 2020. Therefore, you are responsible to pay the $90 copayment. You have been asked to pay a $90 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 February 3, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Entresto tablets.
You asked the Plan to pre-approve Entresto. You say that The Plan denied your request. The Plan says the enrollee's medical plan does not cover outpatient prescription drugs.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Entresto tablets.
Benefits for Entresto may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for a diagnostic mammogram provided on February 6, 2020.
You asked the Plan to waive the deductible for a diagnostic mammogram. You say that this was a breast cancer screening and 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. Your contract with the Plan says that there is a $750 deductible for outpatient diagnostic tests and therapeutic services and supplies. The medical records show that you received a diagnostic mammogram on February 6, 2020. Therefore, you aer responsible to pay your share of the cost-sharing charges. The record shows that you had only paid $182.05 toward the $750 deductible prior to receiving the services. Therefore, you are responsible to pay the total allowed amount of $105.27. The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible for outpatient diagnostic tests and therapeutic services and supplies. This cost sharing is a contractual obligation that had not been met at the time a diagnostic mammogram was received on February 6, 2020. Therefore, we decided that the Plan does not have to waive the deductible for a diagnostic mammogram provided on February 6, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance transportation provided on October 23, 2019.
You asked the Plan to pay for the ambulance transportation. The Plan denied your request. The Plan says the ambulance transport was not medically necessary.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 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 ambulance transportation. Our reviewer says that the requested ambulance transportation was not medically reasonable and necessary. Our physician reviewer found that the documentation does not support that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated for this enrollee on October 23, 2019. The documentation does not support that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped ambulance can provide for safe transport. The enrollee was a 48-year-old woman who reported nausea and abdominal pain. Vital signs were stable. She was described as being in no acute distress. There were no notable findings on physical examination; specifically, there was no tenderness on abdominal exam. The documentation does not support that the ambulance transport on October 23, 2019, was medically reasonable and necessary for this enrollee. 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 ambulance transportation have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance transportation provided on October 23, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the arthroplasty services provided on September 25, 2019.
You asked the Plan to pay for the arthroplasty. The Plan denied your request. The Plan says the records did not document an increased procedural service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 23472 is arthroplasty, glenohumeral joint; total shoulder (glenoid and proximal humeral replacement (e.g., total shoulder)). We asked our coding 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 arthroplasty. Our reviewer found that the medical records provided do not include documentation to support substantial, increased added work for the service performed. Therefore, the addition of Modifier 22 to CPT code 23472 is inappropriate. This cannot be corroborated in the operative report of the enrollee's medical record. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the arthroplasty have not been met. Therefore, we decided that the Plan does not have to pay for the arthroplasty services provided on September 25, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for core build-up tooth 31 (D2950) and crowns teeth 30, 31 (D2740) provided March 9, 2020 to March 25, 2020.
You asked the Plan to pay for the dental services. You say that the 2020 annual notice of plan changes for 2020 and it said $0 copayment for periodontal maintenance services. You took that to mean you'd have $0 copay not that nothing would be covered. The Plan denied your request. The Plan says these services are 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 for core build-up tooth 31 (D2950) and crowns teeth 30, 31 (D2740) provided March 9, 2020 to March 25, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that you went into a diabetic coma and your
wife called for an ambulance to provide help. You stated that the responders brought you back to life. You say
that you would like the Plan to reconsider paying for the charges because you only have Social Security for
your retirement. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when
there is no transport.
The ambulance company did not provide transport services on November 10, 2019. The ambulance benefit is a
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the parenteral nutrition supplies provided from January 11, 2020 to January 17, 2020.
You asked the Plan to waive the coinsurance for the parenteral nutrition supplies. You say that you are unsure why you are receiving this bill. 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 prosthetic devices and related supplies. You have been asked to pay $417.82 which is 20% of the allowed amount for the parenteral nutrition supplies. The total allowed amount is $2,089.10. ($2,089.10 x 20% = $417.82). The parenteral nutrition supplies fall within the "Prosthetic devices 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 waive the coinsurance for the parenteral nutrition supplies provided from January 11, 2020 to January 17, 2020.
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
December 16, 2019 to December 18, 2019.
You asked the Plan to pay for home health services. You say that you would like the Plan to reconsider their
denial of payment. The Plan denied your request. The Plan says the claim was not submitted with the correct
type of bill per Medicare payment guidelines.
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. The rules say the Type of Bill is a required
data element needed to submit a claim under home health PPS. This 4-digit code gives two pieces of
information. The first three digits indicate the base type of bill. The fourth digit indicates the sequence of this
bill in this particular episode of care. The types of bill accepted for HH PPS requests for anticipated payment
are either 7, 8, or 9 as defined above. HHAs must submit HH PPS claims with the 4th digit of "9." Based on
this information, we decided that Medicare rules for completing the claim for home health services have not
been met. Specifically, . Therefore, we decided that the Plan does not have to pay for the home health services
provided to the enrollee from December 16, 2019 to December 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for lumbar-sacral orthosis (L0650) and Ankle foot orthosis RT,
(L1971) provided October 9, 2019.
You asked the Plan to pay for the orthoses. You say that the records provided should support the necessity of
the service in dispute. The Plan denied your request. The Plan says there is no evidence of an established
relationship between the enrollee and the ordering physician, there was no claims submitted for an evaluation
and management service and there is no evidence of a prior telehealth service with the ordering physician as
required per CMS guidelines.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services,
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for
telehealth services only if they are presented from an authorized originating site located in either a county
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located
in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site.
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute
for an in-person encounter. Consequently, the items/services ordered following the non-covered visit are
likewise non-covered. Therefore, we decided that the Plan does not have to pay for lumbar-sacral orthosis
(L0650) and Ankle foot orthosis RT, (L1971) provided October 9, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayments for the wound care provided on October 7,
2019 and October 14, 2019.
You asked the Plan to reduce the copayments for the wound care. You say that you were not aware you would
be charged for outpatient surgery. You say you thought you would only be charged a $40 copayment for the
wound care. 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 $400
copayment per day of service at an outpatient hospital facility.
You have been asked to pay a total of $718.06 copayment for the wound care. The wound care falls within the
"Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical
centers" benefit category. The record shows the wound care is considered a surgical procedure. See chart
below. 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 copayments for the wound care provided on October 7, 2019 and October
14, 2019.