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

We decided that the Plan does not have to waive the coinsurance for heavy duty wheeled walker (E0149) provided on December 19, 2019 by an out-of-network provider.
You asked the Plan to waive the coinsurance for the DME. You say that you should be reimbursed the full 80% of the cost. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The Plan authorized an in-network coverage exception as the heavy-duty wheeled walker had to be purchased from an out-of-network vendor. According to your 2019 EOC, Chapter 4, page 58, it states for in-network Medicare-covered durable medical equipment, you have a 20% coinsurance. Therefore, you are asked to pay 20% coinsurance for the DME. 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 heavy duty wheeled walker (E0149) provided on December 19, 2019 by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Exogen LIPUS osteogenesis stimulator You asked the Plan to pre-approve an osteogenesis stimulator. You say that you would like an osteogenesis stimulator so you can use if after your next surgery to heal properly.The Plan denied your request. The Plan says the information provided by your doctor does not show you have a fracture that has ceased to heal for 3 or more months.The Plan must follow Medicare rules. The rules say that an electrical bone growth stimulator is covered for nonunion of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial radiographs have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment with the electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs separated by a minimum of 90 days.In this case, nonunion of a long bone fracture is not considered to exist under Medicare rules. The file does not show that there were 2 or more serial radiographs separated by 90 or more days confirming that healing had ceased.Therefore, we decided that the Plan does not have to pre-approve a Exogen LIPUS osteogenesis stimulator
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 October 13, 2019 to November 8, 2019.You asked the Plan to pay for home health services. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says a required Q code to indicate where home health services were provided was not reported along with the first billed home health service.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. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the submitted claim does not include the required Q code.Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from October 13, 2019 to November 8, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray rendered on November 4, 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 73562 is not supported.
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 73562 is radiologic examination, knee; 3 views. We find that CPT code 73562 is not supported in the medical record. Specifically, the documentation does not include interpretation and report of a knee x-ray with three views. 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 x-ray rendered on November 4, 2019.
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
October 2, 2019 to October 22, 2019.
You asked the Plan to pay for home health services. You say that you would like reconsideration based on the
records submitted. The Plan denied your request. The Plan says the services have been billed with an invalid
type of bill code.
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. Based on this information, we decided that
Medicare rules for completing the claim for home health services have not been met. Specifically, the
submitted claim does not include a valid type of bill code. Therefore, we decided that the Plan does not have to
pay for the home health services provided to the enrollee from October 2, 2019 to October 22, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound rendered at an outpatient hospital on November 27, 2019.
You asked the Plan to waive the copayment for these services. You say that the services were not performed at an outpatient hospital. The Plan denied your request. The Plan says the copayment was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 copayment per visit for outpatient hospital services.
Review of the file shows that you received an ultrasound at an outpatient hospital facility on November 27, 2019. Per the contract with the Plan, there is a $50 copayment per visit for outpatient hospital services. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. However, the Medicare allowed amount for these services was $22.39. Given that the allowed amount was less than the $50 copayment, you have been asked to pay $22.39 for these services. Therefore, we decided that the Plan does not have to waive the copayment for the ultrasound rendered at an outpatient hospital on November 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for out-of-network (OON) chiropractic spinal manipulation (98941) provided from October 3, 2019 to December 19, 2019.You asked the Plan to waive the copayment for OON chiropractic spinal manipulation. You say that these services should be paid for.The Plan denied your request. The Plan says these services processed correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for each out-of-network Medicare-covered chiropractic visit. You have been asked to pay less than $40 copayment for each chiropractic spinal manipulation due to the allowed amounts for these services. 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 out-of-network (OON) chiropractic spinal manipulation (98941) provided from October 3, 2019 to December 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist services rendered on October 22, 2019.
You asked the Plan to waive the copayment for these services. You say that you disagree with the charges. The Plan denied your request. The Plan says the copayment was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 copayment for in-network specialist's office services.
Review of the file shows that you received specialist physician services on October 22, 2019. You have been asked to pay a $10 copayment for these services. These services fall within the in-network specialist's office 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 specialist services rendered on October 22, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the ankle x-ray provided on August 7, 2019.You asked the Plan to pay for the ankle x-ray. You say that the enrollee had multiple exams on this date. You also say that the reports support the level of service.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 ankle x-ray provided on August 7, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eye exam (92012) provided October 23, 2019.You asked the Plan to pay for the vision services. You say that after your eye exam earlier last year you continued having eyesight problems. You called to requested to see an eye doctor and was surprised when you got an eye exam. You realize you should have opted out.The Plan denied your request. The Plan says this request exceeds the frequency limitation of once a year.Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these 1 routine eye exam (eye refraction exam) per calendar year. Records show that a routine eye exam was provided on June 4, 2019.We looked at the file and the Plan's rules. The plan covers 1 routine eye exam a year. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met.Therefore, we decided that the Plan does not have to pay for eye exam (92012) provided October 23, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided from August 18, 2019 to August 20, 2019.You asked the Plan to pay for the self-administered drugs. You say that you do not have much income.The Plan denied your request. The Plan says self-administrable drugs are not covered while getting hospital outpatient services according to your Medicare Part B Prescription Drug benefit.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 pay for the self-administered drugs provided from August 18, 2019 to August 20, 2019.Benefits for the self-administered drugs 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services rendered on February 17, 2020.You asked the Plan to pay for these services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not payable.The Plan must follow Medicare rules. The rules say that modifier QZ is billed for anesthesia given by a CRNA with a physician involved in one case.We looked at the file and Medicare rules. The file shows that procedure code 00880 was billed with the QZ modifier for the CRNA and billed with modifier AD for the physician, indicating that the procedure was supervised. The QZ modifier is inappropriate in this situation. 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 anesthesia services rendered on February 17, 2020
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for durable medical supplies provided to the enrollee on
December 31, 2019.
You asked the Plan to pay for these supplies. You say that this claim should be paid. The Plan denied your
request. The Plan says the enrollee was under hospice election at the time of service. The Plan states even
though the enrollee revoked hospice on December 30, 2019, the claims are still the responsibility of Original
Medicare until the first day of the following month. The Plan states this claim should be submitted to 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 December 30, 2019. The services in question were provided
(the next day) or before the end of that month. Therefore, we decided that the Plan does not have to pay for
durable medical supplies provided to the enrollee on December 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for non-manipulative services provided on February 20, 2019 through November 20, 2019.
You asked the Plan to pay for the non-manipulative services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the requested service is a non-covered benefit under Medicare and the Plan.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for non-manipulative services provided on February 20, 2019 through November 20, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to hold you harmless for the platelet rich plasma injection services provided on August 5, 2019 minus any cost share amount.
You asked the Plan to pay for the platelet rich plasma injection services. You say that you were told that this service would be covered. The Plan denied your request. The Plan says that the services received are not a covered benefit.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. You were referred and received the platelet rich plasma injection services by a contract provider. The file does not show that the Plan provided notice that the platelet rich plasma injection services would not be covered. Under Medicare rules, this means the platelet rich plasma injection services is considered approved by the Plan. Therefore, we decided that the Plan has to hold you harmless for the platelet rich plasma injection services provided on August 5, 2019 minus any cost share requirements.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy provided on October 22, 2019 to December 17, 2019 by an out of network (OON) provider.
You asked the Plan to pay for physical therapy. You say that you are actually seeing progress with this provider. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that there are in-network providers available for these 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-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 physical therapy provided on October 22, 2019 to December 17, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for comprehensive eye exam (92004) and eye refraction (92015) provided December 5, 2019.You asked the Plan to pay for the vision services. You say that this provider said that you were covered and you went and had the exam and now you received a letter that the plan will not pay for the exam and to send the claim and include a paid receipt.The Plan denied your request. The Plan says this provider is an out of network provider and the plan is unable to reprocess and pay the claim without an itemized receipt.Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan contract says when using an out-of-network provider, you will be responsible for costs above the plan approved amount. You are responsible for submitting an out-of-network claim form with an itemized receipt when seeing an out of network provider.We looked at the file and the Plan's rules. this provider is an out of network provider and the plan is unable to reprocess and pay the claim without an itemized receipt. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met.Therefore, we decided that the Plan does not have to pay for comprehensive eye exam (92004) and eye refraction (92015) provided December 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device.You asked the Plan to pre-approve this back surgery. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested services.The Plan must follow Medicare rules. Medicare rules say that percutaneous image-guided lumbar decompression is only covered when the enrollee is enrolled in a clinical trial.We looked at the file and Medicare rules. Review of the file does not support that the enrollee is enrolled in a clinical trial. Based on this information, we decided that Medicare rules for coverage of this back surgery have not been met.Therefore, we decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the functional outcome assessment and x-ray provided on December 10, 2019.You asked the Plan to pay for the functional outcome assessment and x-ray. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services received are not a covered benefit.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine.Therefore, we decided that the Plan does not have to pay for the functional outcome assessment and x-ray provided on December 10, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided on December 17, 2019 and December 18, 2019.
You asked the Plan to pay for the self-administered drugs. You say that the hospital gave you medicines that were medically necessary to improve your condition. The Plan denied your request. The Plan says the drugs are not covered under your Part B benefit.
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 pay for the self-administered drugs provided on December 17, 2019 and December 18, 2019.
Benefits for the self-administered drugs 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 copayment for a Gastric Emptying Study (78264) provided November 5, 2019.
You asked the Plan to waive the copayment for the gastric emptying study. You say that the copayment should be waived. 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 20% coinsurance for Radiological Diagnostic services. You have been asked to pay a 20% coinsurance for the gastric emptying study. The gastric emptying study falls within the Radiological Diagnostic 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 a Gastric Emptying Study (78264) provided November 5, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve gum surgery.
You asked the Plan to pre-approve gum surgery. You say that this is medically necessary. The Plan denied your request. The Plan says that this 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 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 pre-approve gum surgery.