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

We decided that the Plan does not have to waive the copayment for the emergency room visit provided from September 14, 2020, to September 16, 2020.

You asked the Plan to waive the copayment for the emergency room visit. You say that you did not go to the emergency room for treatment. You went per your doctor's request to be admitted. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $85 copayment for each visit to an emergency room. 

You have been asked to pay a $85 copayment for the emergency room visit. The emergency room visit falls within the "Emergency care" benefit category. The record shows you received outpatient services during this stay. 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 emergency room visit provided from September 14, 2020, to September 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services.

You asked the Plan to pay for these services. You say that you needed to have your teeth removed due to infection. The Plan denied your request. The Plan says you have exhausted the coverage limit.

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. The Plan covers up to $255 every year for supplemental dental benefits.

We looked at the file and the Plan's rules. The file shows that you received dental services for a total of $3,738. The Plan covered the full $255 benefit allowed by your supplemental dental benefit for these services. The remaining balance is not covered by Medicare or your supplemental dental benefit. The extractions are not covered by your Medicare benefit because they were not performed to prepare the jaw for radiation treatment. Therefore, we decided that the Plan does not have to pay for the dental services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral examination (D0140).

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says you have exceeded the allowable benefit for this 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.

We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of this service have not been met. Specifically, the Plan dental policy covers one oral exam every six months. You previously received a comprehensive oral exam, less than six months prior that was paid for by the Plan. Therefore, we decided that the Plan does not have to pay for the limited oral examination (D0140).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuromuscular stimulator, electric shock unit (E0745).

You asked the Plan to pay for this item. You say that the neuromuscular stimulator was medically necessary for the enrollee. The Plan denied your request. The Plan says the documentation indicates that the item at issue was not necessary for the treatment of the enrollee's condition.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

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 this item. Our reviewer says that the neuromuscular stimulator is not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee's chief complaint was ankle pain. Diagnoses of primary osteoarthritis of the right and left ankles and feet, pain in the right and left ankles and the joints of both feet, and muscle wasting and atrophy of the right and left lower legs are listed in the exam notes. A physical examination of the ankles and feet would reasonably be required to adequately assess whether the coverage criteria were met. The documentation does not support that the neuromuscular stimulator was medically reasonable and necessary in this case as there is insufficient documentation of a credible physical examination of the ankles and feet.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this item have not been met. Therefore, we decided that the Plan does not have to pay for the neuromuscular stimulator, electric shock unit (E0745).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services.

You asked the Plan to pay for the physician's services. 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 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 physician's services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for Computed Tomography angiography (CTA) scans of the chest and abdomen/pelvis.

You asked the Plan to waive the copayments for CTA scans. You say that you have the understanding that the radiology copayment is $155 per visit. The Plan denied your request. The Plan says the copayment amounts you are being charged are 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 $155 copayment for each CTA scan. There were 2 scans, resulting in a total copayment amount of $310.

You have been asked to pay $155 copayment for each CTA scan. CTA scans fall 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 copayments for Computed Tomography angiography (CTA) scans of the chest and abdomen/pelvis.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the wig, any type (A9282) purchased July 29, 2020 from an out of network provider.
You asked the Plan to pay for the wig. You say that you are appealing the denial of reimbursement for an essential wig due to loss of hair from chemo treatments. The Plan denied your request. The Plan says this item is not a covered benefit as it is not used to serve a medical purpose.
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are ordered by a physician. The Plan follows these same rules. In this case, although the wig may be appropriate, it does not meet the definition of the above benefit categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would provide coverage for a wig. Therefore, we decided that the Plan does not have to pay for the wig, any type (A9282) purchased July 29, 2020 from an out of network provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health visits.
You asked the Plan to pre-approve the home health visits. The Plan denied your request. The Plan says the
home health visits do not meet criteria.
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is
due and the amount of payment.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the home health visits have not been met. Therefore, we decided that the Plan does not have to preapprove
home health visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for neuropathy treatment and electrical stimulation.

You asked the Plan to pay for the neuropathy treatment and electrical stimulation. 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 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 neuropathy treatment and electrical stimulation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical extraction (D7210), the initial 15 minutes of intravenous moderate sedation (D9239), and the additional 15 minutes of intravenous moderate sedation (D9243 x 2) provided on September 18, 2020.

You asked the Plan to pay for the dental services. You say that even though the surgery was done in your mouth to remove a tooth, it was in fact a surgery and not a basic tooth removal. You also say that this procedure was done under intravenous sedation and partial bone had to be removed. The Plan denied your request. The Plan says the surgical extraction is not listed as covered service. The Plan says coverage is provided for analgesia which is represented by code D9230. The Plan also says that intravenous moderate sedation is not 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 requested items or services are not among those covered under this benefit. Additionally, the Evidence of Coverage clearly states that anesthesia is covered as needed when provided with other covered procedures. Surgical extraction is not a covered service and therefore the intravenous moderate sedation would not be covered either. Therefore, we decided that the Plan does not have to pay for the surgical extraction (D7210), the initial 15 minutes of intravenous moderate sedation (D9239), and the additional 15 minutes of intravenous moderate sedation (D9243 x 2) provided on September 18, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy provided by a participating provider on August 18, 2020, to August 28, 2020.

You asked the Plan to waive the copayment for physical therapy. You say that this was not an outpatient hospital. 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 $40 copayment for outpatient rehabilitation services/physical therapy/outpatient hospital. 

You have been asked to pay a $40 copayment for each physical therapy. The total amount you are being asked to pay is $160 ($40 x 4 visits = $160). These services were provided in a special hospital facility; therefore, the correct copayments have been applied. Physical therapy falls within the outpatient rehabilitation services/physical therapy/outpatient hospital 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 by a participating provider on August 18, 2020, to August 28, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for drug infusion administration and the drug provided from February 7, 2019, to April 17, 2019.

You asked the Plan to waive the copayments for drug infusion administration (96413) and the drug (J1746). You say that you were taking infusion for over a year and your copayment was much less. The Plan denied your request. The Plan says you were charged this coinsurance correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for Medicare Part B Prescription Drugs and 20% coinsurance for administration. 

You have been asked to pay 20% coinsurance for drug infusion administration and the drug. The drug infusion administration and drug fall within the Medicare Part B Prescription Drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for drug infusion administration and the drug provided from February 7, 2019, to April 17, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the Cardiac Rehabilitation (93797, 93798) provided from June 2, 2020, through July 31, 2020.

You asked the Plan to waive the copayments for the Cardiac Rehabilitation. You say that you were told by someone at the provider's office that there would be no fee for the services. The Plan denied your request. The Plan says the copayments were 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 $15 copayment for each Cardiac rehabilitation visit. 

You have been asked to pay a total of $465 ($15 copayment x 31 visits) for the Cardiac Rehabilitation. This service falls within the Cardiac rehabilitation services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the Cardiac Rehabilitation (93797, 93798) provided from June 2, 2020, through July 31, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to a skilled nursing facility (SNF) for the enrollee.You asked the Planto pre-approvethe admission. You say that the enrollee does not feel safe going home with the current mobility concerns.The Plandenied your request. The Plansaysthe criteria was not met.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We asked our physicianreviewer 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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis ina skilled nursing facility setting.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 admission have not been met.Therefore, we decided that the Plandoes not haveto pre-approveadmission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forambulance services (A0428, A0425) provided on July 18, 2020.You asked the Plan to pay forambulance services. You say that this should be covered.The Plan denied your request. The Plan says this was not billed correctly.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Coding of a sequela diagnosis generally requires two codes sequenced in the following order: the condition or nature of the sequela is sequenced first. The sequela code is sequenced second.We find the billing of these services is not supported in the medical record. Specifically, these services were billed with the sequela diagnosis T14.90XS (Injury, unspecified, sequela) as the primary diagnosis. Based on this information, we decided that Medicare rules for coverage of ambulance services have not been met.Therefore, we decided that the Plan does not have to pay forambulance services (A0428, A0425) provided on July 18, 2020.Your complaint about being billed for these services and needing the provider to submit a corrected claim 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (73630) provided July 28, 2020.

You asked the Plan to pay for the radiology services. You say that the service should be paid. The Plan denied your request. The Plan says the deductible was not met at the time services were rendered.

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 $245 deductible for x-rays. 

The item or service you asked the Plan to pay for falls within the benefit category x-rays. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $245 deductible for x-rays. This cost sharing is a contractual obligation that had not been met at the time the radiology services was received on July 28, 2020. Therefore, we decided that the Plan does not have to pay for radiology services (73630) provided July 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for lumbar-sacral orthosis, sagittal-coronal control, (L0650).

You asked the Plan to pay for lumbar-sacral orthosis. You say that the item is medically necessary. The Plan
denied your request. The Plan says you did not present any medical records showing that the prescribing
physician ever saw the member.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.

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 lumbar-sacral orthosis. Our reviewer says
that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found 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 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 lumbar-sacral orthosis have not been met. Specifically, there was insufficient
documentation showing the criteria for this item was met. This means the item is not medically necessary or
reasonable. Therefore, we decided that the Plan does not have to pay for lumbar-sacral orthosis, sagittalcoronal
control, (L0650).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services provided on October 16, 2019.
You asked the Plan to pay for the critical care services. You say that the medical records provided support that payment should be made for the services in dispute. The Plan denied your request. The Plan says the claim denied due to an invalid/missing modifier.
The Plan must follow Medicare rules. Medicare rules say that for coverage to be considered and payment issued, the information submitted by the supplier or provider must corroborate the documentation in the enrollee's medical documentation and confirm that Medicare coverage criteria have been met. We looked at the file and Medicare rules. The records provided do not include a progress note showing critical care services were provided by the doctor whose name is on the claim in dispute. This means that the claim is not supported. Based on this information, we decided that Medicare rules for coverage of the critical care services have not been met. Therefore, we decided that the Plan does not have to pay for critical care services provided on October 16, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation, surgical extraction, and
primary closure of a sinus perforation provided on May 20, 2020, by an OON provider.
You asked the Plan to pay for the comprehensive oral evaluation, surgical extraction, and primary closure of a
sinus perforation. You say that you were not aware that the services rendered by this provider would not be
covered by your dental plan. The Plan denied your request. The Plan says the services were rendered by a noncontracted
provider.
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
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the
comprehensive oral evaluation, surgical extraction, and primary closure of a sinus perforation provided on May
20, 2020, by an OON provider.