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

We decided that the Plan does not have to pay for orthotics (L0637-NU) billed to the enrollee for date of
service July 9, 2019.
You asked the Plan to pay for this orthotic. You say that this claim should be paid. The Plan denied your
request. The Plan says the records provided do not include valid proof of delivery or valid physicians order.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a
physician order and proof of delivery. The record does not contain a valid physician order and/or proof of
delivery for the supplies provided in this case. Therefore, we decided that the Plan does not have to pay for
orthotics (L0637-NU) billed to the enrollee for date of service July 9, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation feature, and medical necessities bag from Numotion.
You asked the Plan to pre-approve the power seat elevation feature and medical necessities bag. You say that the power wheelchair and accessories are medically necessary. The Plan denied your request. The Plan says a power seat lift elevation system and a medical necessities bag do not serve a medical purpose and are not covered.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. Medicare rules say options and accessories for wheelchairs are covered if the beneficiary has a wheelchair that meets Medicare coverage criteria and the option/accessory itself is medically necessary. The items at issue in this appeal do not serve a purpose that is primarily medical in nature. These items are available to the general public and would be helpful even to those who are not sick or injured. A power seat elevation feature is statutorily non-covered. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation feature or a medical accessories bag.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and the prophylaxis (D1110) provided on November 4, 2019.
You asked the Plan to pay for the dental services. You say that the services you received were preventative. The Plan denied your request. The Plan says the oral exam and prophylaxis are not listed as 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 oral exam and prophylaxis are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and the prophylaxis (D1110) provided on November 4, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the surgery provided on November 1, 2019 by an in-network provider.
You asked the Plan to waive the copayment for the surgery. You say that the surgery was approved and this should be covered. 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). Review of the file show that you received the surgery on November 1, 2019 by an in-network provider. You are asked to pay a $175 copayment for the surgery. 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 surgery provided on November 1, 2019 by an in-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe re-evaluation of a limited oral evaluation (D0170) and a resin based composite, 1 surface, for a posterior tooth (D2391) provided from September 23, 2019 to October 8, 2019.You asked the Plan to pay forthe dental services. You say that when you signed up for your plan, you were advised you would keep your preventive care and $500 comprehensive coverage with an additional $1,000 for comprehensive dental services.The Plan denied your request. The Plan says the annual maximum of $500 has been exceeded.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 annual maximum of $500 has been exceeded.Date of ServiceBilled AmountAllowed AmountPlan Paid9/11/2019$331$264.80$264.809/18/2019$2,670$2,136$235.20TOTAL:$500Therefore, we decided that the Plan does not have to pay forthe re-evaluation of a limited oral evaluation (D0170) and a resin based composite, 1 surface, for a posterior tooth (D2391) provided from September 23, 2019 to October 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a shoulder orthosis provided on July 18, 2019.
You asked the Plan to pay for the shoulder orthosis. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.
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 did not pre-approve the shoulder orthosis. We found no exception that would require the Plan to pay for this item. Therefore, we decided that the Plan does not have to pay for a shoulder orthosis provided on July 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on January 21, 2019 and February 19, 2019.
You asked the Plan to pay for the dental services. You say that the Plan's customer service representative told you that this provider was in network and that the expenses would be covered by your insurance. The Plan denied your request. The Plan says these services are covered at your selected primary care dentist office only. The Plan also says that you have not chosen a primary care dentist.
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 when they are received from a dentist other than your Network Primary Dentist. Therefore, we decided that the Plan does not have to pay for the dental services provided on January 21, 2019 and February 19, 2019.
Your complaint about initially being given misinformation by the customer service representative is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe specialist office visit provided on August 6, 2019.You asked the Plan to waive the copayment forthe specialist office visit. You say that you would like this bill to be paid. 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 andcoinsurance). Your contract with the Plan clearly says that you must pay a $30 copayment for services obtained form an in-network specialist, or under certain circumstances, treatment by a nurse practitioner or physician's assistant or other non-physicianhealth care professionals in a specialist's office. 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. 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 August 6, 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 requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not medically necessary.
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 admission to a LTACH is not medically necessary. Our physician reviewer found in the case of this enrollee, attempts to wean from mechanical ventilation related to pneumonia, acute kidney injury, and liver failure had initially failed and it was recently stated that the enrollee was "unstable" and at "high risk of deterioration due to the ongoing medical issues. Transfer to LTACH would not be safe due to this instability, and although ongoing acute care is still needed, there was no indication the required services would not be able to be continued and covered at the current facility. There was no unique treatment proposed at the LTACH to help justify transfer at this time. Therefore, this request for LTACH services will be considered not medically necessary at this time. 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy provided from June 21,
2019 through June 28, 2019.
You asked the Plan to waive the copayment for physical therapy. You say that you were informed the provider
would receive pre-approval from the Plan. You say that a copayment was never discussed. The Plan denied
your request. The Plan says the copayments 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 for each Medicare-covered in-network therapy visit.
You have been asked to pay $120 for physical therapy. ($40/visit x 3 visits = $120). Physical therapy falls
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 copayment
for physical therapy provided from June 21, 2019 through June 28, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from November 29, 2018 through December 5, 2018 provided to the enrollee.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you are appealing the member's cost-share responsibility for the services the member received. The Plan denied your request. The Plan says the claim was processed accordingly with the member's 2018 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 the enrollee received inpatient hospital care from November 29, 2018 through December 5, 2018. The enrollee is asked to pay a $300 copayment for the inpatient hospital care. 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 inpatient hospital care from November 29, 2018 through December 5, 2018 provided to the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forthe triamcinolone acetonide injection rendered on October 3, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code J3301 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 J3301 is injection, triamcinolone acetonide, not otherwise specified, 10 mg.We find that CPT code J3301 is not supported in the medical record. Specifically, there is no documentation that a total of 160 mg was administered on the date of service at issue. 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 forthe triamcinolone acetonide injection rendered on October 3, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from October 16,
2019 through October 20, 2019.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you are appealing your
cost-share responsibility for the services you received. 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).
Review of the file shows that you were admitted on October 16, 2019 and discharged on October 20, 2019.
You were asked to pay a $225 copayment per day from October 16, 2019 through October 19, 2019, days 1-4
of your inpatient hospital care. You were discharged on October 20, 2019 and there was no copayment charge
for the day of discharge. Per your contract there is a $225 copayment per day required for days 1-5. 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 care from October 16, 2019 through October 20,
2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveinpatient mental health care, for the enrollee.You asked the Plan to pre-approveinpatient mental health care. You say that the stay was medically necessary.The Plan denied your request. The Plan says the stay is not medically necessary.The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient mental health care. Our physician reviewer found based upon review the records provided, this patient does not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of February 8, 2020 forward and could have been treated in a lesser restrictive setting as he was not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions and was not showing any behaviors or aggression being cooperative and compliant.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient mental health care have not been met.Therefore, we decided that the Plan does not have to pre-approveinpatient mental health care, for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve and addition (L1833, L2397, L2810) provided to the enrollee on September 19, 2019.
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 there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. Therefore, we decided that the Plan does not have to pay for a knee orthosis with suspension sleeve and addition (L1833, L2397, L2810) provided to the enrollee on September 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve routine eye exam and eye glasses.You asked the Plan to pre-approve the vision services. You say that you need an eye exam and new prescription because your eyesight has changed and you cannot see well with your current glasses.The Plan denied your request. The Plan says the benefits has been exhausted for the requested services.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 up to $300 for eyeglasses (frames and lenses) or contact lenses every 2 years and 1 routine eye exam every year. The plan says that you will be eligible for your next eye exam on March 1, 2020. However you will not be available to use the eyewear benefit until March 1, 2021 as you had used the eyewear benefit in March 2019.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 vision services have not been met.Therefore, we decided that the Plan does not have to pre-approve routine eye exam and eye glasses.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora left knee orthosis (L1833-LT), a left suspension sleeve (L2397-LT), and a right wrist orthosis (L3916-RT) provided to the enrollee on August 6, 2018.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 encounter appears to be a Telehealth service encounter however Telehealth guidelines have not been met.The Plan must follow Medicare rules.Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay fora left knee orthosis (L1833-LT), a left suspension sleeve (L2397-LT), and a right wrist orthosis (L3916-RT) provided to the enrollee on August 6, 2018.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran MRI provided on December 1, 2017.You asked the Plan to waive the copayment foran MRI. You say that you disagree with the denial of 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 $175 copayment for advanced imaging services provided at a freestanding radiological facility. You have been asked to pay a $175 copayment for an MRI. An MRI falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment foran MRI provided on December 1, 2017.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean implant supported crown (D6066) for teeth # 30 and 31.You asked the Plan to pre-approvethe dental services. You say that the enrollee was previously approved for implant surgery for teeth # 30 and 31. You also say that this is a continuous implant procedure.The Plan denied your request. The Plan says implant supported crowns are not a covered service.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, implant supported crowns are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvean implant supported crown (D6066) for teeth # 30 and 31.