Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services provided October 30 to October 31, 2019.You asked the Plan to waive the copayment for the inpatient services. You say that the copayment should be waived.The Plan denied your request. The Plan says the correct copay was 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 $295 per day copayment for days 1 through 4 of each inpatient stay. You have been asked to pay a $295 per day copayment for 1 day of inpatient care. 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 inpatient hospital services provided October 30 to October 31, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two problem focused limited oral evaluations, two first intraoral periapical x-rays, and three root canals provided on December 23, 2019 and January 6, 2020.You asked the Plan to pay for the problem focused limited oral evaluations, intraoral periapical x-rays, and three root canals. You say that when you called to schedule the appointment, you were told that this provider accepted your insurance. You also say that after the services were rendered, you were told that this provider did not accept your insurance.The Plan denied your request. The Plan says the treating provider is an opt out provider until October 13, 2020.The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the treating provider. This provider has opted out of the Medicare program. The file shows that this provider entered into a private contract with you regarding payment.Therefore, we decided that the Plan does not have to pay for the two problem focused limited oral evaluations, two first intraoral periapical x-rays, and three root canals provided on December 23, 2019 and January 6, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided on August 9, 2019 to November 30, 2019.
You asked the Plan to pay for the SNF services. You say that the records provided should support the necessity of the services in dispute. The Plan denied your request. The Plan says services obtained from a provider who is not a certified Medicare provider.
Medicare rules say that no provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless the provider and supplier enroll in the Medicare program. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided on August 9, 2019 to November 30, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete maxillary denture (D5110) and complete mandibular denture (D5120).
You asked the Plan to pay for the complete maxillary denture and complete mandibular denture. You say that your previous dentures never fit correctly, but you kept them. You also say that you have had them for two years and since then they have broken, are missing teeth, and you have had to wear them glued. The Plan denied your request. The Plan says these services exceed the maximum allowed per period.
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, complete maxillary denture (D5110) and complete mandibular denture (D5120) are each limited to one procedure every five plan years. The record shows that you received a complete maxillary denture (D5110) and your complete maxillary denture benefit has been exhausted. The record also shows that you received a complete mandibular denture (D5120) and your complete mandibular denture benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the complete maxillary denture (D5110) and complete mandibular denture (D5120).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on December 6, 2019.You asked the Plan to waive the copayment for the office visit. You say that the provider made the appointment with the wound clinic. You say that you shouldn't have to pay for this.The Plan denied your request. The Plan says the copayment applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 copayment for each in-network specialist visit for Medicare-covered services. You have been asked to pay $20.53, which is less than the standard $35 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office 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 office visit provided on December 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the wig, any type (A9282) and sales tax (S9999) provided August 22, 2019.You asked the Plan to pay for the wig. You say that you have read the benefit book relating prosthesis devices and do not see this listed under exclusions. Please reconsider this unjustified decision.The Plan denied your request. The Plan says this service is not a covered benefit.Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are ordered by a physician. The Plan follows these same rules.In this case, although the wig may be appropriate,it does not meet the definition of the above benefit categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As such, it is non-covered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would provide coverage for a wig.Therefore, we decided that the Plan does not have to pay for the wig, any type (A9282) and sales tax (S9999) provided August 22, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient lab work provided on January 17, 2020 by an out
of network (OON) provider.
You asked the Plan to pay for outpatient lab work. You say that you would like this claim reprocessed and
approved for payment. The Plan denied your request. The Plan says the ordering physician is out-of-network.
The Plan says that no prior authorization was obtained.
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 outpatient lab work provided
by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on January 14, 2020.
You asked the Plan to waive the copayment for a specialist visit. You say that you disagree with the charges because this was a follow-up visit and you saw a physician's assistant. 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 $35 copayment for each specialist visit. You had a specialist visit on January 14, 2020. Follow-up visits are subject to cost-sharing charges. Therefore, you are responsible to pay the $35 copayment. You have been asked to pay a $35 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office 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 a specialist visit provided on January 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on December 18,
2019.
You asked the Plan to waive the copayment for a specialist 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 $45
copayment for services obtained by a specialist.
You have been asked to pay a $45 copayment for a specialist visit. A specialist visit falls within the
physician/practitioner services, including doctor's office 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 a specialist visit provided on December 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for podiatry services provided on April 15, 2019 by an out of network (OON) provider. You asked the Plan to pay for podiatry services. You say that you would like this appeal reprocessed and approved for payment. The Plan denied your request. The Plan says these services could have been provided in-network.
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 podiatry services provided on April 15, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve posterior tibial nerve stimulation (PTNS).
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says that PTNS used as maintenance therapy is considered investigational.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician reviewer found that the enrollee has overactive bladder that responded well to a 12-week course of PTNS treatments. He also has a history of benign prostatic hyperplasia that was treated with Urolift. Voiding symptoms have not responded to Tamsulosin or Myrbetriq. PTNS treatments were very effective and allowed the enrollee to stop taking anticholinergic medication. Maintenance PTNS treatments on an every 3-weeks basis should be extended to enrollees who demonstrate significant improvement of overactive bladder symptoms at the end of a standard 12-week course of therapy. As such, the requested services are medically reasonable and necessary for the 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 requested services have been met. Therefore, we decided that the Plan has to pre-approve posterior tibial nerve stimulation (PTNS).
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic exercises provided by an out of network (OON) provider.
You asked the Plan to pay for therapeutic exercises. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the referring provider is also out-of-network.
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 therapeutic exercises provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe eye exam provided on January 15, 2020.You asked the Plan to waive the copayment forthe eye exam. You say that this was a routine exam. You say that there is no cost.The Plan denied your request. The Plan says the copayment applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment per visit for Medicare-covered exams to diagnose and treat diseases of the eye.You have been asked to pay a $40 copayment for the eye exam. The eye exam falls within the "Vision care" benefit category. The records show that a medical eye exam was performed. 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 eye exam provided on January 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the dialysis services provided from July 1,
2019 to November 29, 2019.
You asked the Plan to waive the cost share for the dialysis services. You say that you were told you would
meet your out-of-pocket maximum. The Plan denied your request. The Plan says the claims were processed
correctly with a coinsurance.
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 20%
coinsurance for renal dialysis services.
You have been asked to pay a 20% coinsurance for the dialysis services. The records do not show that you
reached your maximum out-of-pocket amount at the time the claims were processed. The dialysis services fall
within the services to treat kidney disease 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 cost share
for the dialysis services provided from July 1, 2019 to November 29, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve N95 respirators.
You asked the Plan to pre-approve the N95 masks. You say that the masks are medically necessary. The Plan
denied your request. The Plan says the masks are not a covered item.
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-approve N95 respirators.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient psychotherapy (90839 and 90840) provided on January 16, 2019.
You asked the Plan to pay for the outpatient psychotherapy services. You say that you would like reconsideration because you were told you were covered for individual outpatient psychotherapy. The Plan denied your request. The Plan says this provider does not meet Medicare's standards of non-physician practitioners.
The Plan must follow Medicare rules. Medicare rules say that Licensed Marriage and Family Therapists and Licensed Professional Counselors are not eligible to enroll in Medicare.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the outpatient psychotherapy services have not been met. Specifically, this provider is not eligible to participate in Medicare. Therefore, we decided that the Plan does not have to pay for outpatient psychotherapy (90839 and 90840) provided on January 16, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic, prophylactic, or diagnostic injection, laboratory services, noninvasive ear or pulse oximetry for oxygen saturation injection, self-administrable drugs, and hospital outpatient clinic visit provided.
You asked the Plan to pay for the therapeutic, prophylactic, or diagnostic injection, laboratory services, noninvasive ear or pulse oximetry, self-administrable drugs, and hospital outpatient clinic visit. You say that the claim has not been paid in full or under the terms of the contract for the services provided to this enrollee. 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 for the therapeutic, prophylactic, or diagnostic injection, laboratory services, noninvasive ear or pulse oximetry for oxygen saturation injection, self-administrable drugs, and hospital outpatient clinic visit provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core buildup, including any pins when required, provided on December 26, 2019.
You asked the Plan to pay for the core buildup. You say that you called the Plan prior to receiving the services and were told that a partial was covered. You also say that you cannot afford to pay for the core buildup. The Plan denied your request. The Plan says this service 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. 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 core buildup, including any pins when required, provided on December 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for more than 30 minutes of hospital discharge day management services (99239) provided on May 1, 2019 through May 4, 2019.
You asked the Plan to pay for the hospital discharge day management services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation does not support that more than 30 minutes of hospital discharge day management services were provided.
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 99239 is hospital discharge day management; more than 30 minutes. We find that CPT code 99239 is not supported in the medical record. Specifically, the record does not indicate that more than 30 minutes of hospital discharge day management services were rendered. Based on this information, we decided that Medicare rules for coverage of the hospital discharge day management services have not been met. Therefore, we decided that the Plan does not have to pay for more than 30 minutes of hospital discharge day management services (99239) provided on May 1, 2019 through May 4, 2019.