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

We decided that the Plan does not have to pay for the two extractions of an erupted tooth or exposed root
(D7140 x2) and two extractions of an erupted tooth requiring removal of bone and/or sectioning of tooth
(D7210 x2) provided on January 28, 2020.
You asked the Plan to pay for the extractions. You say that these services were necessary for the placement of
dentures of the upper teeth and removal of a lower decayed tooth. You also say that you feel the denial of
payment is in error and all extractions should be covered. The Plan denied your request. The Plan says you
exceeded limits set in the subscriber agreement. The Plan also says that your $1,000 maximum had been met
while processing this claim.
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 Plan offers a $1,000 annual dental
benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are
responsible for the full charges of any additional dental services. The record shows that you met the annual
maximum benefit on January 28, 2020 and your annual maximum benefit has been exhausted. Therefore, we
decided that the Plan does not have to pay for the two extractions of an erupted tooth or exposed root (D7140
x2) and two extractions of an erupted tooth requiring removal of bone and/or sectioning of tooth (D7210 x2)
provided on January 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network chiropractic services provided on January 15,
2020.
You asked the Plan to pay for this service. You say that this service should be covered by the Plan. The Plan
denied your request. The Plan says you did not have prior authorization for out of network care and you were
referred by an out of network provider. In addition, the chiropractic services rendered are not covered by
Medicare.
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 Plan contract also says chiropractic services may require
prior authorization.
The provider in this case is not a network provider with the Plan. You were referred by an out of network
provider. You did not have prior authorization. The services provided are not covered by Medicare. We found
no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not
have to pay for out of network chiropractic services provided on January 15, 2020.
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 office visit. You say that you feel that this provider is the best chance to save your vision. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this provider is out-of-network with the Plan and you can be treated by an in-network tertiary level of care provider. The Plan also says that if, after evaluation with an in-network provider, the provider feels that this out-of-network provider is necessary, then the out-of-network provider could be approved.
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9500) provided on January 1, 2020
through January 3, 2020.
You asked the Plan to pay for the home infusion therapy.. You say that you would like reconsideration based
on the records submitted. The Plan denied your request. The Plan says CPT code S9500 has a status code of I
which is not valid for Medicare purposes.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT code S9500 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT
code S9500 has a status code of I. This means that CPT code S9500 is not valid for Medicare purposes. Based
on this information, we decided that Medicare rules for coverage of the home infusion therapy. have not been
met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9500) provided on
January 1, 2020 through January 3, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for an outpatient visit (99214) provided on November 25, 2019. You asked the Plan to pay for the outpatient visit. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that nurse practitioners are not eligible for payment. The Plan must follow Medicare rules. Medicare rules say that in order to be eligible, nurse practitioners must be billing for their services under their own NPI and not furnishing services incident to physicians' services. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the outpatient visit have been met. Specifically, the provider in this case is a NP, for which Medicare states payment can be made. The NP has their own NPI on the claim form. Therefore, we decided that the Plan has to pay for an outpatient visit (99214) provided on November 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power wheelchair repairs.
You asked the Plan to pre-approve power wheelchair repairs. You say that the enrollee's power wheelchair
needs repair but a replacement appears to be more cost effective. The Plan denied your request. The Plan says
the expense for repairs exceeds estimated cost of replacement. The Plan says they opened a new authorization
request for a new power wheelchair and accessories request.
The Plan must follow Medicare rules. Medicare rules say that only services that are medically necessary and
reasonable will be covered.
We looked at the file and Medicare rules. The cost of repairs exceeds the cost of replacement. Based on this
information, we decided that Medicare rules for coverage of power wheelchair repairs have not been met.
Therefore, we decided that the Plan does not have to pre-approve power wheelchair repairs.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the upgraded electronics.
You asked the Plan to pre-approve the power wheelchair Electronic connection (E2311), Expandable controller
harness (E2313), and Expandable controller (E2377). You say that the enrollee needs a Group 2 power
wheelchair and accessories. The Plan denied your request. The Plan says the electronic upgrades cannot be
covered as it is not medically necessary to control the three approved power options through the joystick.
The Plan follows Medicare rules. Medicare rules say that 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.
Documentation shows that the enrollee has 4/5 strength in the bilateral upper limbs. Upper limb strength is
adequate for the enrollee to be able to control the power options using their own switches which are included in the allowance of these power options. This means that Medicare rules for coverage of a PMD have not been
met. Therefore, we decided that the Plan does not have to pre-approve the upgraded electronics.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an MRI provided on March 2, 2020.
You asked the Plan to waive the coinsurance for an MRI. 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 20%
coinsurance for diagnostic imaging.
You received an MRI on March 2, 2020. The total allowed amount is $2,419.64 and 20% of that is $483.93.
You have been asked to pay the total coinsurance amount of $483.93 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 coinsurance for an MRI provided on March 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist services provided on January 7,
2020.
You asked the Plan to waive the copayment for specialist services. You say that you disagree with 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 $30
copayment for specialist services.
You have been asked to pay a $30 copayment for specialist services. Specialist services fall 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 for specialist services provided on January 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for specialist visits provided on February 4,
2020 and February 12, 2020.
You asked the Plan to waive the copayments for specialist visits. You say that you saw your primary care
physician and disagree with 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 $40
copayment for specialist services.
The record shows that you had specialist visits on February 4, 2020 and February 12, 2020. Therefore, you are
responsible to pay a $40 copayment per each visit. The total amount you owe is: $80.
You have been asked to pay the total copayment amount of $80 for specialist visits. Specialist visits fall 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 copayments for specialist visits provided on February 4, 2020 and February 12, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-ofnetwork
provider on July 18, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network
deficiency for these services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that
the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider
on July 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for vision services (V2799) deluxe frames (V2020) bifocal lenses (V2202) purchased November 27, 2019.
You asked the Plan to pay for the eyeglasses. You say that you were told that you had a benefit allowance of $150 and that if you went outside of the Plan for glasses and spent more than that you would only be reimbursed for $150. The Plan denied your request. The Plan says you must receive your vision services from an in-network provider.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when purchased from an n-network provider. We looked at the file and the Plan's rules. you must receive your vision services from a network provider. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met.
Therefore, we decided that the Plan does not have to pay for vision services (V2799) deluxe frames (V2020) bifocal lenses (V2202) purchased November 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on January 7, 2020.
You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says that
the Plan requires utilization of network providers when possible and available, and requires authorization for
certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency
situation, has been documented.
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
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we
decided that the Plan does not have to pay for a domiciliary, rest home visit provided on January 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 99190) provided on August 30, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment for this service is included in the Part A DRG payment to the facility.
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. Payment for all fees related to this service would have been included under the facility claim. Therefore, we decided that the Plan does not have to pay for the services (CPT 99190) provided on August 30, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from May 26, 2019 to May 30, 2019.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you feel that if you were treated properly you would not have required the stay. 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 $395 copayment per day for days 1-4 for inpatient hospital care. You had an inpatient hospital stay from May 26, 2019 to May 30, 2019. Therefore, you are responsible to pay a $395 copayment for days 1-4 (May 26, 2019 to May 29, 2019). $395 (copayment) x 4 (inpatient days) = $1,580. You have been asked to pay the total copayment amount of $1,580 for 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 provided from May 26, 2019 to May 30, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from November 7,
2019, to November 10, 2019.
You asked the Plan to pay for the acute inpatient hospital care. The Plan denied your request. The Plan says
inpatient care was not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.
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 acute inpatient hospital care. Our
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this
case. Our physician reviewer found that based on the records provided at the time of inpatient admission, care
at the observation level appeared to be appropriate, with the option to move the enrollee to inpatient status
when and if it became clear that the enrollee's hospital stay would span two midnights.
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 acute inpatient hospital care have not been met. Therefore, we decided that
the Plan does not have to pay for the acute inpatient hospital care provided from November 7, 2019, to
November 10, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 15, 2019 by an out of network (OON) provider.
You asked the Plan to pay for Oncotype Dx testing. You say that no basis exists for the Plan to deny this test as a non-covered service. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and prior authorization for this testing was denied by the Plan.
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 October 15, 2019 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that the claim was a result of a 911 emergency
dispatch call to the enrollee's home. You say that the claim should be paid even though the enrollee refused to
be transported to the hospital. The Plan denied your request. The Plan says these services are not a covered
benefit.
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 December 25, 2019. 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 ambulance services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the aspiration of the bladder provided on
January 17, 2020.
You asked the Plan to waive the copayment for the aspiration of the bladder. You say that you should only owe
a specialist copayment because you did not receive a surgical procedure and disagree with 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 $350
copayment for surgery services provided in an outpatient hospital facility.
You received the aspiration of the bladder on January 17, 2020 at an outpatient hospital facility. The aspiration
of the bladder is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $350
copayment.
You have been asked to pay a $350 copayment for the aspiration of the bladder. The aspiration of the bladder
falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory
surgical centers 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 aspiration of the
bladder provided on January 17, 2020.