Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe reline of a complete maxillary denture and reline of a complete mandibular denture provided on January 2, 2020.You asked the Plan to pay forthe denture relines. You say that when the dental representative contacted the Plan, she was told the Plan pays every 6 months. You also say that when you had your dentures relined previously, they did not do a good job and you needed to do something to ease the discomfort.The Plan denied your request. The Plan says these services exceeded the frequency limitations of your dental 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, coverage of tissue conditioning, relining, or rebasing is limited to once in a 2 year period. The record shows that you received an upper and lower denture reline on March 27, 2018 and your denture reline benefit has been exhausted.Therefore, we decided that the Plan does not have to pay forthe reline of a complete maxillary denture and reline of a complete mandibular denture provided on January 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe vision exam provided on January 10, 2020.You asked the Plan to waive the copayment forthe vision exam. You say that you were seen for a film under your cataracts. You say the provider did the same service that the previous provider had just done two hours prior. 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 $50 copayment per Medicare-covered visit. You have been asked to pay a $50 copayment for the vision exam. The vision exam falls within the "Vision care" benefit category. The records show you were diagnosed with secondary cataracts in the left eye, which makes the vision exam medical in nature.This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is acontractual 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 vision exam provided on January 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forbilateral knee orthoses (L1833) and suspension sleeves (L2397) provided to the enrollee on December 18, 2019.You asked the Plan to pay forthe orthoses and sleeves. You say that the durable medical equipment is medically necessary.The Plan denied your request. The Plan says the services are not supported by the records.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the orthoses and sleeves have not been met. Documentation submitted did not indicate the provider discussed the need for the billed supply code; therefore the billed supply code cannot be verified.Therefore, we decided that the Plan does not have to pay forbilateral knee orthoses (L1833) and suspension sleeves (L2397) provided to the enrollee on December 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe specialist office visit provided on June 7, 2019.You asked the Plan to waive the copayment forthe specialist office visit. You say that you should not pay the copayment because nothing was done. The Plandenied 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 $30 copayment for each specialist visit for Medicare-covered services. You have been asked to pay a $30 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The medical record shows that you had an office visit on June 7, 2019. 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 specialist office visit provided on June 7, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for psychotherapy services provided from December 3, 2019 to January 7, 2020.You asked the Plan to waive the deductible for psychotherapy services. You say that you were told that you would only owe a $40 copayment per each service.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 $650 deductible for out-of-network outpatient mental health care.You received out-of-network psychotherapy services on December 3, 2019. The record shows that you had paid $0 toward the $650 deductible prior to receiving the services. Therefore, you are responsible to pay the allowed amount of $200.You received out-of-network psychotherapy services on January 7, 2020. The record shows that you had paid $0 toward the $650 deductible prior to receiving the services. Therefore, you are responsible to pay the allowed amount of $75. The total amount you owe is: $275.  The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient mental health care. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $650 deductible for out-of-network outpatient mental health care. This cost sharing is a contractual obligation that had not been met at the time psychotherapy services was received on December 3, 2019 to January 7, 2020.Therefore, we decided that the Plan does not have to waive the deductible for psychotherapy services provided from December 3, 2019 to January 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wheelchair ramp.You asked the Plan to pre-approve a wheelchair ramp. You say that you need the wheelchair ramp in order to enter and exit your home.The Plan denied your request. The Plan says wheelchair ramps are not covered by Medicare or the Plan.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. Also, the item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home.Therefore, we decided that the Plan does not have to pre-approve a wheelchair ramp.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from December 5, 2019 to December 14, 2019.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says Skilled Nursing Facility (SNF) care beyond 100 days per benefit period is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. The file shows that the enrollee received 100 days of SNF care during the benefit period from June 29, 2019 to December 4, 2019. The Plan has covered 100 days of SNF care. Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. the enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from December 5, 2019 to December 14, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuromuscular junction testing provided on
You asked the Plan to pay for the neuromuscular junction testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 95937 is neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method. We find that CPT code 95937 is not supported in the medical record. Specifically, this code represents neuromuscular junction testing. The documentation indicates that train of four testing/monitoring was performed. It is inappropriate to bill the code for neuromuscular junction testing for train of four monitoring. Based on this information, we decided that Medicare rules for coverage of the neuromuscular junction testing have not been met. Therefore, we decided that the Plan does not have to pay for the neuromuscular junction testing provided on
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided on January 14, 2020.
You asked the Plan to waive the copayment for an office visit. You say that you disagree with the charges because this was an annual wellness visit. 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 $10 copayment for each primary care provider visit. The claim was submitted with multiple diagnostic codes. Therefore, the office visit you had on January 14, 2020 went beyond an annual wellness visit. Therefore, you are responsible to pay the $10 copayment. You have been asked to pay a $10 copayment for an office visit. An 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 an office visit provided on January 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvefacet joint radiofrequency ablation (64635, 64636).You asked the Plan to pre-approvethis service. You say that you are requesting a reconsideration of the Plan's denial.The Plan denied your request. The Plan says that the enrollee does not meet criteria for coverage of the requested procedure.The Plan follows Medicare rules. Medicare rules say that repeat denervation procedures involving the same joint will only be considered medically necessary if the patient experienced >50% improvement of pain and improvement in patient specific ADLs documented for at least 6 months. 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 this service. Our reviewer says that the enrollee does not meet criteria for coverage of this service. Our physician reviewer found that criteria for facet joint radiofrequency ablationhavenot been met. There is no documentation of > 50% relief ofpain and functional improvement from previous injections.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have not been met.Therefore, we decided that the Plan does not have to pre-approvefacet joint radiofrequency ablation (64635, 64636).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a home visit provided on December 19, 2019 by an out of network (OON) provider.
You asked the Plan to pay for a home visit. You say that you depend on the hospital staff to verify eligibility. You say that your provider provides these services in good faith. The Plan denied your request. The Plan says 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 a home visit provided on December 19, 2019 by an out of network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care (99291) and discharge services (99238) provided
from July 16, 2019 to July 17, 2019.
You asked the Plan to pay for critical care and discharge services. You say that hospice is not responsible for
these services. The Plan denied your request. The Plan says payment for these services is the responsibility of
Original Medicare.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Original Medicare is responsible for payment for services until the first day of the month after the
hospice election has been revoked or terminated.
The enrollee ended Medicare Hospice benefits on July 16, 2019. The services in question were provided before
the end of that month. Therefore, we decided that the Plan does not have to pay for critical care (99291) and
discharge services (99238) provided from July 16, 2019 to July 17, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the hearing aids (V5257) purchased October 17, 2019 to October 18, 2019.
You asked the Plan to pre-approve the hearing aids. You say that you had called the plan and was told that the plan cover's $500 per hear and you went somewhere and was told that they take all insurances. The Plan denied your request. The Plan says services are covered only when rendered by a participating provider.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when rendered by a participating provider. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pre-approve the hearing aids (V5257) purchased October 17, 2019 to October 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for Equipment Rental Package (E1399RR) provided on September 17, 2019.
You asked the Plan to pay for the item. You say that the ophthalmologist told you that if you did not keep a face down position you would go blind. The Plan denied your request. The Plan says this item does not meet the definition of DME and therefore, is not reasonable and necessary.
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 pay for Equipment Rental Package (E1399RR) provided on September 17, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on November 12, 2019 by a non-network provider.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 were rendered by a non-network provider.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The referring provider 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 forthe medical services provided on November 12, 2019 by a non-network provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room (ER) and electrocardiogram (EKG) services rendered on December 27, 2019.
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 were not billed correctly.
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis code. We looked at the file and Medicare rules. The file shows that the claim was billed without an appropriate primary or principal diagnosis. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the emergency room (ER) and electrocardiogram (EKG) services rendered on December 27, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for bilateral knee orthoses (L1833) and suspension sleeves (L2397) provided to the enrollee on December 23, 2019.
You asked the Plan to pay for the orthoses and sleeves. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says the services are not supported by the records.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the orthoses and sleeves have not been met. No medical records were received to support the diagnosis on the submitted order; therefore, the bill code cannot be supported. Therefore, we decided that the Plan does not have to pay for bilateral knee orthoses (L1833) and suspension sleeves (L2397) provided to the enrollee on December 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial observation care rendered on July 25, 2019.
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 99220 is not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. The provider submitted a claim for procedure codes 99220 and 36906. Code 99220 is a column II code with a modifier indicator of 1 when billed with column I code 36906. Code 99220 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the initial observation care rendered on July 25, 2019.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pay for CPT code 76856 provided on September 30, 2019.
You asked the Plan to pay for CPT code 76856. You say that the medical records support the billing of CPT code 76856. The Plan denied your request. The Plan says that the medical records do not support the billing of CPT code 76856.
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 76856 is Ultrasound, pelvic (nonobstetric), real time with image documentation; complete. 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 CPT code 76856. Our reviewer says that the medical records support the billing of CPT code 76856. Our physician reviewer found the report of the pelvic ultrasound of 9/30/19 describes transvesical and endovaginal scanning in the technique portion. This technique entails both the transabdominal and transvaginal techniques of scanning required for billing of 76856. The confusion lies in the term transvesical. This type of scanning is synonymous with transabdominal and thus qualifies for the submitted code. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CPT code 76856 have been met. Therefore, we decided that the Plan has to pay for CPT code 76856 provided on September 30, 2019.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power operated vehicle.
You asked the Plan to pre-approve an electric scooter. You say that you need an electric scooter around your
house and one that can be folded up into your vehicle trunk. The Plan denied your request. The Plan says your
assessment shows a power operated vehicle is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.
The file shows that you do not have a mobility deficit that impairs your participation in MRADLs. This means
that Medicare rules for coverage of a PMD have not been met. The item at issue in this appeal is being
requested for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan cover
PMDs for use only outside the home. Therefore, we decided that the Plan does not have to pre-approve a power
operated vehicle.