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

We decided that the Plan does not have to reimburse you for the hearing aids providedon July 28, 2020.You asked the Plan to reimburse you for the hearing aids. You say that the hearing aids purchased out-of-network were quite a bit better than the hearing aids being offered under the Plan's program. The Plan denied your request. The Plan says you must see the Plan's hearing provider to use the hearing aid benefit.Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when provided by the Plan's hearing aid provider.We looked at the file and the Plan's rules. The file shows that you received the hearing aids from a provider that is not part of the Plan's hearing aid benefit provider. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to reimburse you for hearing aids providedon July 28, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay foroutpatient mental health services (CPT 99213) provided to the enrollee on June 24, 2020.You asked the Plan to pay forthe services. You say that this should be paid for.The Plan denied your request. The Plan says this did not include the appropriate primary, first-listed or principal diagnosis.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 99213 is "Office or other outpatient visit for the evaluation and management of an establishedpatient, which requires two of these three key components:-An expanded problem focused history-An expanded problem focused examination-Medical decision making of low complexity Documentation to support this service should include, but is not limited to the following: Medicare allows only the medically necessary portion of the visit. Even if a complete note is generated, only the necessary services for the condition of the patient at the time of the visit can be considered in determining the level of an E/M code."We asked our coding 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our coding reviewer found the documentation did not include provider documentation to verify the code.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 services have not been met.Therefore, we decided that the Plan does not have to pay foroutpatient mental health services (CPT 99213) provided to the enrollee on June 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ostomy supplies provided on May 29, 2020. 
 
You asked the Plan to pay for the ostomy supplies. You say that the manager at the enrollee's facility signed for 
these supplies. The Plan denied your request. The Plan says there is no proof of delivery despite multiple 
requests for this documentation. 
 
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 proof of delivery for the billed items. The signature indicated by the 
provider does not indicate the billed date of service and also does not clearly state what was delivered and 
signed for. There is an order number referenced but there is no delivery ticket with the matching order number 
to verify what was included. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for the ostomy 
supplies provided on May 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forphysician services provided to the enrollee on July 14, 2020 and billed under codes 95955-26-59 and 51785-26.You asked the Plan to pay forthis service. You say that these services should be paid by the Plan. The Plan denied your request. The Plan says this case involves an inappropriate billing of (CPT) code 95955-26-59and 51785-26. The Plan says the technical report did not include documentation of needle electromyography studies (EMG) of anal or urethral sphincter, using any technique. The procedure code was not documented in the medical records submitted. These codes have both a technical and professional component. When codes 51784 or 51785 are performed with another separately identifiable procedure, the highest dollar value code is listed as the primary procedure and subsequent procedures are appended with modifier 51. It should be noted code 51784 should not be reported with 51792. The description of this code was not documented in the operative report narrative.The Plan states that according to (CPT) code definitionsand guidance, these codes were inappropriatelybilled. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT codes.In this case, review of the medical records provided does not show the documentation supports the codes billed. Therefore, we decided that the Plan does not have to pay forphysician services provided to the enrollee on July 14, 2020 and billed under codes 95955-26-59 and 51785-26
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approveCPT Code 64494, 64495 and 64493.You asked the Plan to pre-approvethe services. You say that the member is having muscle spasms, weakness, and pain scores of 3-4/10 when walking.The Plan denied your request. The Plan says the services are not necessary.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rulesto determine if the Plan was correct in denying the request to pre-approve the services. Our physician reviewer found the criteria for facet joint injections have not been met. Records indicate low levels of pain and radicular complaints.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 services have not been met.Therefore, we decided that the Plan does not have to pre-approveCPT Code 64494, 64495 and 64493.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a heavy duty, extra wide hospital bed.

You asked the Plan to pre-approve a heavy duty, extra wide hospital bed. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says you do not meet criteria for the requested item.

The Plan must follow Medicare rules. The rules say that a hospital bed may be considered medically necessary when at least one of the following criteria is met:

1. The patient has a medical conditions which requires positioning of the body in ways not feasible with an ordinary bed; or

2. The patient requires positioning of the body in ways not feasible with an ordinary bed in order to alleviate pain; or

3. The patient requires the head of the bed to be elevated more than 30 degrees most of the time due to congestive heart failure, chronic pulmonary disease, or problems with aspiration. Pillows or wedges must have been considered and ruled out; or

4. The patient requires traction equipment, which can only be attached to a hospital bed.

We looked at the file and Medicare rules. The requested type of heavy duty hospital bed is only covered for enrollee's who weigh more than 350 pounds and less than 600 pounds. Review of the file shows that you weigh 155 pounds. Based on this information, we decided that Medicare rules for coverage of a heavy duty, extra wide hospital bed have not been met.Therefore, we decided that the Plan does not have to pre-approve a heavy duty, extra wide hospital bed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for new patient outpatient office visit (99202) electrical 
stimulation (G0283) established patient outpatient office visit (99212) occupational therapy exercises (97110) 
provided. 
 
You asked the Plan to pay for the chiropractic services. You say that the services provided were vital to your 
health. The procedures have improved your overall well-being and you are able to walk pain free for the first 
time in many months. The Plan denied your request. The Plan says these services are not covered under the 
plan benefits. 
 
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 new patient outpatient office visit (99202) electrical stimulation (G0283) 
established patient outpatient office visit (99212) occupational therapy exercises (97110) provided.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the co payment for the ultrasound provided. 
 
You asked the Plan to waive the co payment for the ultrasound. You say that the ultrasound was approved. The 
Plan denied your request. The Plan says the co payment 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 $100 
copayment for all other diagnostic tests.  
 
You have been asked to pay $90.29, which is less than the standard $100 copayment for the ultrasound. The 
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 the ultrasound provided .
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided to the enrollee. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says Medicare denies coverage for lab assays of two or more genes in an enrollee in parallel. 
Those two or more genes will be considered part of the same panel. A panel constitutes a single procedural 
service, so one HCPCS code must be submitted for the panel.  
 
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, this claim cannot be paid as billed 
because there is a request for separate payment of a code or assay panel that is included within another code 
billed. Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does 
not have to pay for lab services provided to the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the diagnostic mammogram provided on 
August 11, 2020. 
 
You asked the Plan to waive the copayment for the diagnostic mammogram. You say that the hospital coded 
the mammogram and ultrasound incorrectly as an x-ray. You say that you are not paying because the hospital 
coded it wrong. The Plan denied your request. The Plan says the copayment 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 $35 per 
day, per provider, for Medicare-covered x-ray services.  
 
You have been asked to pay a $35 copayment for the diagnostic mammogram. The diagnostic mammogram 
falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The records 
show that the mammogram was ordered for diagnostic purposes. 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 diagnostic mammogram provided on August 11, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care provided on August 12, 2020. 
 
You asked the Plan to pay for the initial hospital care. You say that the Plan should pay this claim. The Plan 
denied your request. The Plan says the claim cannot be paid. 
 
The Plan must follow Medicare rules. The rules state that instead of billing separately, the physicians should 
select a level of service representative of the combined visits and submit the appropriate code for that level.  

Therefore, we decided that the Plan does not have to pay for the initial hospital care provided on August 12, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the CT angiography provided on August 
26, 2020. 
 
You asked the Plan to waive the copayment for the CT angiography. You say that your confirmation does not 
say that you would be responsible to pay more than a standard x-ray copayment. The Plan denied your request. 
The Plan says the copayment 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 $100 
copayment for each Medicare-covered MRI, CT or PET scan from an in-network provider.  
 
You have been asked to pay a $100 copayment for the CT angiography. The CT angiography 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 the CT angiography provided on August 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a retainer crown on tooth #4 (D6242) and a pontic on 
tooth #5 (D6751). 
 
You asked the Plan to pre-approve a retainer crown on tooth #4 and a pontic on tooth #5. You say that this is 
necessary. The Plan denied your request. The Plan says this exceeds the frequency limitations on these services. 
 
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 
covered only once every five years per tooth. The record shows that you received services on the teeth at issue 
in October 2019. Therefore, we decided that the Plan does not have to pre-approve a retainer crown on tooth #4 
(D6242) and a pontic on tooth #5 (D6751).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the neurophysiological monitoring provided on March 22, 
2019. 
 
You asked the Plan to pay for the neurophysiological monitoring (95941). You say that the claim was filed 
timely. The Plan denied your request. The Plan says the claim was untimely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the neurophysiological monitoring (95941) was not filed until July 30, 2020. 
This means that more than one calendar year from the date of service had passed before a claim was filed.  
Therefore, we decided that the Plan does not have to pay for the neurophysiological monitoring provided on 
March 22, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy provided on 
September 18, 2020. 
 
You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that you feel you should 
not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan 
denied your request. The Plan says you received a diagnostic colonoscopy on the date of service at issue in this 
appeal. The Plan says that the correct copayment has applied per your contract with the Plan. 
 
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 $400 
copayment for Medicare-covered outpatient hospital surgery services.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received a diagnostic 
colonoscopy on September 18, 2020 with removal of a polyp. You have been asked to pay a $400 copayment 
for the diagnostic colonoscopy. The diagnostic colonoscopy falls within the Outpatient hospital 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 diagnostic colonoscopy provided on 
September 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crown - porcelain/ceramic, tooth #30 (D2740). 
 
You asked the Plan to pre-approve the dental services. You say that the service is necessary. The Plan denied 
your request. The Plan says the member exhausted their 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. As per research the D2740 
crown-porcelain/ceramic tooth number 30 was received on December 06, 2018. Code D2740 is covered one 
procedure per tooth every five plan years. Therefore, we decided that the Plan does not have to pre-approve 
crown - porcelain/ceramic, tooth #30 (D2740).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a 
participating provider on May 12, 2020, to May 18, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that this copayment is too 
high. 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 $390 
copayment per day for days 1-5. There is a $0 copayment for additional days for inpatient hospital care.  
 
You have been asked to pay a $390 copayment per day for days 1-5 for an inpatient hospital stay. The total 
amount you are being asked to pay is $1,950 ($390 x 5 days = $1,950). 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 provided by a participating provider on May 12, 2020, to May 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265). 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that the enrollee's condition requires 
this item. The Plan denied your request. The Plan says this is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed (E0265).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 5, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that this provider is out-of-network, so no 
authorization was obtained. The Plan denied your request. The Plan says the provider of these services is not a 
Plan provider.  In addition, the provider of service did not request authorization from the Plan prior to these 
services being rendered.  The Plan says that unauthorized, non-plan care is not a covered benefit. 
 
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 the medical services provided on August 5, 2020 
by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve aquatic therapy. 
 
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your 
request. The Plan says it is not clear from the records why this was requested. 
 
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 pre-approve the therapy. 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 records do not demonstrate that the unique skills of a professional 
therapist are required to safely and effectively provide treatment. The documentation does not support that the 
requested services are part of a maintenance program. 
 
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 therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve aquatic therapy.