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

We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided August 25, 2020.
You asked the Plan to pay for the lumbar-sacral orthosis. You say that the requested item was medically necessary. The Plan denied your request. The Plan says there is no evidence that the prescribing physician ever saw the member.
The Plan follows Medicare rules. Medicare rules say that a spinal orthosis will be covered when the Medicare criteria cited in the Rules section are met. 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 the lumbar-sacral orthosis. Our reviewer says that the lumbar-sacral orthosis is not medically necessary and reasonable. Our physician reviewer found an appropriate history and a physical examination of the back would reasonably be required to adequately
assess whether the coverage criteria for a lumbar-sacral orthosis have been met. The documentation does not support that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as there is insufficient documentation of a credible evaluation and a credible physical examination of the back. 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 lumbar-sacral orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided August 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the work related or medical disability evaluation services (99455) provided June 17, 2020.
You asked the Plan to pay for the work related or medical disability evaluation service. You say that there should have only been one $90 charge for a DOT physical and the accidentally billed twice. You are trying to get reimbursement for the $90 copay. The Plan denied your request. The Plan says the services provided is not covered by the plan as they are employment related.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at this the file and Medicare rules. This service was related to employment rather than for medical necessity and is non-covered services. Based on this information, we decided that Medicare rules for coverage of the work related or medical disability evaluation service have not been met. Therefore, we decided that the Plan does not have to pay for the work related or medical disability evaluation services (99455) provided June 17, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the visit to the emergency department (99283) on October 24, 2020.
You asked the Plan to waive the copayment for the emergency room visit. You say that you do not feel you should have an emergency room copayment because you were seen in express care. The Plan denied your request. The Plan says this service was billed as an emergency room service by the emergency department.
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 $100 copayment for emergency care. You have been asked to pay a $100 copayment for the emergency room visit. Services were provided by the emergency department. 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 visit to the emergency department (99283) on October 24, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services (no transport) received on May 25, 2020.
You asked the Plan to pay for the services. You say that you didn't want to expose yourself to COVID-19 at the emergency room. The Plan denied your request. The Plan says this is not covered under any normal circumstances.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on May 25, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for ambulance services (no transport) received on May 25, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on November 18, 2020.
You asked the Plan to pay for the services provided. You say that you fell from your chair and were unable to get up. The Plan denied your request. The Plan says your coverage does not provide for this service.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on November 18, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the medical services provided on November 18, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to provide additional physical therapy visits.
You asked the Plan to provide additional physical therapy visits. You say that the enrollee is working on equipment not available at home. The Plan denied your request. The Plan says based on the clinical information provided the enrollee has minimal impairments remaining.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 provide additional physical therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the patient has had prior therapy for this condition and the records do not demonstrate that the patient's functional level needs more therapy visits with the unique skills of a professional therapist to safely and effectively provide treatment, or that the services can be safely and effectively performed only by a therapist, or for physical therapy, by or under the supervision of a therapist. The patient can be educated in a home exercise program with the 2 additional authorized therapy visits. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the patient's current condition or to prevent or slow further deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to provide additional physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0676).

You asked the Plan to pay for a pneumatic compression device. You say that the requested item is medically necessary. The Plan denied your request. The Plan says the requested item is not covered by Medicare.

The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service.

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0676).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services.

You asked the Plan to pay for the office visit and x-rays. You say that you went to the chiropractor for pain relief. The Plan denied your request. The Plan says they only cover manual manipulation of the spine to correct subluxation.

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 services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the chiropractic services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgery and coinsurance for an injection provided by a participating provider.

You asked the Plan to waive the copayment for an outpatient surgery and coinsurance for an injection. You say that you do not agree with these extra charges. The Plan denied your request. The Plan says the correct copayment and coinsurance 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 $295 copayment for outpatient surgery and a 20% coinsurance for Medicare Part B prescription drugs/in-network.

You have been asked to pay a $295 copayment for an outpatient surgery and less than a 20% coinsurance of the allowed amount for an injection. The total allowed amount is $486.07. Your total coinsurance amount is $97.21 ($486.07 x 20% = $97.21). You are being asked to pay a lesser amount ($91.71) which is less than your 20% coinsurance. The total amount you are being asked to pay is $386.71 ($295 + $91.71 = $386.71). An outpatient surgery falls within the outpatient surgery benefit category and an injection falls within the Medicare Part B prescription drugs/in-network 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 outpatient surgery and coinsurance for an injection provided by a participating provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (80307, G0483).

You asked the Plan to pay for drug testing. You say that this was medically necessary. The Plan denied your request. The Plan says this was billed with an incorrect POS.

The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS).

We looked at the file and Medicare rules. The services at issue were billed with POS 81 for an independent laboratory, but the records indicate that the sample was not taken in a laboratory. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing (80307, G0483).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound provided on October 30, 2020.
You asked the Plan to waive the copayment for an ultrasound. You say that you feel that the ultrasound should be included in part of the mammogram screening. 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 $100 copayment for ultrasounds. You received an ultrasound on October 30, 2020. Ultrasounds are not included in breast cancer screenings. Therefore, you are responsible to pay the allowed amount of $93.54, which is less than the $100 copayment. You have been asked to pay $93.54 for an ultrasound. An ultrasound 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 for an ultrasound provided on October 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the removal of torus mandibularis (D7473).

You asked the Plan to pay for the removal of torus mandibularis. You say that you were not advised that this procedure would not be covered. The Plan denied your request. The Plan says this service is not covered 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. Therefore, we decided that the Plan does not have to pay for the removal of torus mandibularis (D7473).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for portable x-ray services (Q0092, R0070).

You asked the Plan to pay for portable x-ray services. You say that this was billed correctly. The Plan denied your request. The Plan says this was billed with an incorrect POS.

The Plan must follow Medicare rules. Medicare rules say POS) code 31 should be used with services for patients in a Part A covered stay and POS code 32 should be used with services for beneficiaries in a noncovered stay.

We looked at the file and Medicare rules. The services at issue were billed with POS 31, but the record indicates that the enrollee was in a non-covered skilled nursing facility stay. Based on this information, we decided that Medicare rules for coverage of portable x-ray services have not been met. Therefore, we decided that the Plan does not have to pay for portable x-ray services (Q0092, R0070).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care.

You asked the Plan to waive the copayment for emergency care. You say that you feel that you should not be responsible for the charges because your cardiologist told you to go to the emergency room. 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 $90 copayment for emergency care.

You have been asked to pay a $90 copayment for emergency care. Emergency care falls within the emergency 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 emergency care.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (80307, G0482).

You asked the Plan to pay for drug testing. You say that this is supported by the records. The Plan denied your request. The Plan says this was billed with an incorrect POS.

The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS).

We looked at the file and Medicare rules. The services at issue were billed with POS 81 for an independent laboratory, but the records indicate that the sample was not taken in a laboratory. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing (80307, G0482).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility care provided by an out-of-network provider on November 2, 2020.
You asked the Plan to pay for the nursing facility care. You say that the treatment was medically necessary, and payment should be granted. The Plan denied your request. The Plan says prior authorization is required for out-of-network 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 had network providers available who could have provided 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 the nursing facility care provided by an out-of-network provider on November 2, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the physical therapy services (97110, 97112, 97162) provided from October 12, 2020 to October 30, 2020.
You asked the Plan to waive the copayment for physical therapy. You say that you are concerned because the bill shows a different total each time and you feel the copayment is too high. The Plan denied your request. The Plan says outpatient therapy has a $35 copayment per day. You may have received different types of therapies (therapeutic exercises, neuromuscular reeducation, physical therapy evaluation) on any given day, and therefore the total amount the provider bills the Plan may vary. However, your copayment will not exceed $35 for each day of outpatient rehabilitation services.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 copayment for outpatient rehabilitation services. You have been asked to pay a $315 copayment for 9 days of physical therapy ($35 x 9 days = $315). 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 the physical therapy services (97110, 97112, 97162) provided from October 12, 2020 to October 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the lab testing services provided on December 9, 2020.
You asked the Plan to waive the deductible for the lab services. You say there should be no cost-sharing responsibility for these services because you had them the same day as your annual wellness visit. The Plan denied your request. The Plan says the annual wellness visit was correctly billed with no copay required, but lab testing services are a separate service with their own cost-share requirements. Lab testing has a $0 copayment once the deductible is met, but at the time of service you had not met your required $250 deductible.
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 $250 deductible that applies to laboratory tests. The item or service you asked the Plan to waive the deductible for falls within the benefit category laboratory tests. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $250 deductible for laboratory tests. This cost sharing is a contractual obligation that had not been met at the time the lab services was received on December 9, 2020. Therefore, we decided that the Plan does not have to waive the deductible for the lab testing services provided on December 9, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance transportation provided on September 23, 2020.
You asked the Plan to waive the copayment for ambulance transport. You say that this was an emergency. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.
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 $325 copayment per trip ambulance transportation. You have been asked to pay the allowed amount of $311.20, which is less than the $325 copayment for ambulance transport. Ambulance transport falls within the Ambulance 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 ambulance transportation provided on September 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you the $300 allowance towards the 1-year gym membership you purchased on October 2, 2020.
You asked the Plan to reimburse you the entire allowance for the 1-year gym membership you purchased on October 2, 2020. You say that you should receive the entire allowance since you purchased the membership while a member. The Plan denied your request. The Plan says they reimbursed you the allowance prorated.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers gym benefits with a $300 allowance each calendar year towards your cost for membership in a qualified health club or fitness facility. The Plan's rules for coverage of 1-year gym benefits have not been met because you were only a member from October 1, 2020, to December 31, 2020. Therefore, we decided that the Plan does not have to reimburse you the full $300 allowance towards the 1-year gym membership you purchased on October 2, 2020.