Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the laboratory work provided on December 24, 2019.
You asked the Plan to waive the deductible for the laboratory work. You say that these services were a part of your diabetes screening and you should not have a copayment or deductible. 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. Your contract with the Plan says that there is a $600 deductible that applies towards Medicare-covered lab services. The laboratory work you asked the Plan to waive the deductible for falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $600 deductible that applies towards Medicare-covered lab services. The record shows a diagnosis of diabetes prior to receiving the laboratory work. This means that the laboratory work is considered diagnostic in nature.
This cost sharing is a contractual obligation that had not been met at the time the laboratory work was received on December 24, 2019. Therefore, we decided that the Plan does not have to waive the deductible for laboratory work provided on December 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the chiropractic services. You say that you would like reconsideration because your preferred provider is 5 miles away. The Plan denied your request. The Plan says the requested service can be provided by an in-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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for neurophysiology monitoring (95940) provided on October 9, 2019.
You asked the Plan to pay for the neuromonitoring. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the service billed.
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 95940 is continuous intraoperative neurophysiology monitoring in the operating room, one on one monitoring requiring personal attendance, each 15 minutes (List separately in addition to code for primary procedure) We asked our coder 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 neuromonitoring. Our reviewer says that CPT code 95940 does not meet criteria for billing or reimbursement consideration. Our reviewer found the documentation does not state one on one monitoring requiring personal attendance. 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 neuromonitoring have not been met. Therefore, we decided that the Plan does not have to pay for neurophysiology monitoring (95940) provided on October 9, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for bilateral ankle-foot orthoses (L1971) provided to the enrollee on January 16, 2020.
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use. The record shows that documentation submitted did not indicate the provider discussed the need for the billed supply code, so the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to pay for bilateral ankle-foot orthoses (L1971) provided to the enrollee on January 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Part B injection provided on March 18, 2020. You asked the Plan to waive the coinsurance for the Part B injection. You say that you cannot afford this bill and you say you were under the impression there was no 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 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay $2,319.03 which is 20% allowed amount for the Part B injection. The allowed amount is $11,595.17. ($11,595.17 x 20% = $2,319.03). The Part B injection falls within the "Medicare Part B prescription drugs" 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 Part B injection provided on March 18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from June 11, 2019 to June 28, 2019.You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you cannot afford 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 $265 copayment each day for days 1-8 for inpatient hospital care. You had an inpatient hospital stay from June 11, 2019 to June 28, 2019. Therefore, you are responsible to pay a $265 copayment for days 1-8 (June 11, 2019 to June 18, 2019). $265 (copayment) x 8(inpatient days) = $2,120.You have been asked to pay the total copayment amount of $2,120for an inpatient hospital stay. An 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 an inpatient hospital stay from June 11, 2019 to June 28, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two core buildups, including any pins when required (D2950 x2) and occlusal guard (D9944).
You asked the Plan to pre-approve the core buildups and occlusal guard. You say that a plan representative told you that your insurance does cover crowns, but does not cover the posts in the crowns. You also say that your dentist requested a mouth guard so that you would do no damage to your other crowns. The Plan denied your request. The Plan says Medicare does not cover this service and therefore this service is not covered by your 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 pre-approve two core buildups, including any pins when required (D2950 x2) and occlusal guard (D9944).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for comprehensive oral evaluation - new or established patient (D0150), bitewings - four radiographic images (D0274), intraoral - periapical radiographic image (D0220) and surgical removal of residual tooth roots (cutting procedure) (D7250) provided from January 6, 2020 through January 21, 2020 by an in-network provider.
You asked the Plan to pay for the dental services. You say that the provider used the wrong codes. The Plan denied your request. The Plan says the services are not a covered benefit 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. The services are not listed in your EOC as a covered benefit; therefore, the services are not covered. Therefore, we decided that the Plan does not have to pay for comprehensive oral evaluation - new or established patient (D0150), bitewings - four radiographic images (D0274), intraoral - periapical radiographic image (D0220) and surgical removal of residual tooth roots (cutting procedure) (D7250) provided from January 6, 2020 through January 21, 2020 by an in-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on February 5, 2020.
You asked the Plan to pay for the pump assembly and operation. You say that you would like reconsideration because it takes 30 minutes to set up the machine and the perfusionist is required to be in the operating room during the length of the procedure. The Plan denied your request. The Plan says payment for this service is the responsibility of the facility to any vendor.
The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the pump assembly and operation have not been met. Specifically, payment for this service is included in the DRG payment to the facility and is the responsibility of the facility to any vendor. Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on February 5, 2020.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for medical nutrition therapy provided on December 4, 2019.
You asked the Plan to pay for medical nutrition therapy services. You say that you would like reconsideration because the medical nutrition therapy was medically necessary and appropriate. The Plan denied your request. The Plan says medical nutrition therapy is covered by Medicare only for diabetes and renal disease, or for non-functioning structures that normally permit food to reach the stomach and digestive tract.
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services only for enrollees with renal disease or diabetes. Records do not show that the enrollee suffers from renal disease or diabetes. Therefore, we decided that the Plan does not have to pay for medical nutrition therapy provided on December 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Prolia injection provided on December 27, 2019.
You asked the Plan to waive the coinsurance for the Prolia injection. You say that you don't understand the increase in price. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for chemotherapy drugs and 20% coinsurance for all other drugs covered under Medicare Part B. You have been asked to pay $169.12, which is 20% of the allowed amount for the Prolia injection. The allowed amount is $845.58 (20% x $845.58 = $169.12). The Prolia injection falls within the "Medicare Part B prescription drugs" 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 Prolia injection provided on December 27, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for complete denture - maxillary (D5110) and complete denture - mandibular (D5120) provided on December 16, 2019.
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says the services are not a covered benefit 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. The services are not listed in your EOC as a covered benefit; therefore, the services are not covered. Therefore, we decided that the Plan does not have to pay for complete denture - maxillary (D5110) and complete denture - mandibular (D5120) provided on December 16, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee will require a prolonged
hospital stay and LTACH facilities are better equipped to treat this type of patient. The Plan denied your
request. The Plan says the enrollee's needs can be met in the current facility.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
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 LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found the patient is currently undergoing treatment at an ACH following a subarachnoid
hemorrhage. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services
that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is
no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such
time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for
any ongoing LTC needs.
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 LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an X-ray provided on December 10, 2019.
You asked the Plan to waive the copayment for an X-ray. You say that you disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $20 copayment for X-rays. The enrollee has been asked to pay a $20 copayment for an X-ray. An X-ray falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an X-ray provided on December 10, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the speech therapy visits provided from October 30, 2019 to November 27, 2019. You asked the Plan to waive the copayments for the speech therapy visits. You say that you were told by the receptionist that the visits were free and covered by insurance. 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 $40 copayment for each Medicare-covered physical therapy and speech-language therapy visit. You have been asked to pay a $40 copayment for each of the speech therapy visits. The speech therapy visits fall within the "Outpatient Rehabilitation 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 copayments for the speech therapy visits provided from October 30, 2019 to November 27, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for molecular pathology provided on January 7, 2020 by an out of network (OON) provider.
You asked the Plan to pay for molecular pathology. You say that you would like the original determination reconsidered due to these services being medically necessary. The Plan denied your request. The Plan says the referring provider 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 molecular pathology provided on January 7, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics (L1971, L3170) provided August 19, 2019.
You asked the Plan to pay for foot orthotics. You say that the orthotics were medically necessary. The Plan
denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.
Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace.
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pay for foot orthotics
(L1971, L3170) provided August 19, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for computed tomographic (CT) angiography of the chest provided on October 13, 2019.
You asked the Plan to pay for the CT scan. The Plan denied your request. The Plan says duplicate claims are not payable.
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined to be exact duplicates of another claim are denied.
We find that the CT scan at issue has been previously billed and paid for by the Plan. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for computed tomographic (CT) angiography of the chest provided on October 13, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the DME provided from November 27, 2018 through January 27, 2019.
You asked the Plan to waive the coinsurance for the DME. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claims were processed accordingly with your 2018 and 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). Review of the file show that you received the DME provided from November 27, 2018 through January 27, 2019. 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 the DME provided from November 27, 2018 through January 27, 2019.