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

We decided that the Plan does not have to pre-approve a semi-electric hospital bed.
You asked the Plan to pre-approve a semi-electric hospital bed. You say that the enrollee has fallen out of bed a few times and needs to be able to adjust the bed to the correct elevation. The Plan denied your request. The Plan says there is no documentation that the enrollee meets criteria.
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient: 1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 2. Requires attachments which can only be attached to a hospital bed; AND 3. Requires frequent changes in body position and/or has an immediate need for a change in body position. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a semi-electric hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve a semi-electric hospital bed.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the radiation treatment provided December
12, 2019.
You asked the Plan to waive the copayment for the radiation treatment. You say that you should not be liable
for the cost share due to the high cost. 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 $60
copayment for each in-network Medicare-covered radiation (radium and isotope) therapy service.
You have been asked to pay a $60 copayment for the radiation treatment. The radiation treatment 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 radiation treatment provided on December 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe specialist office visit providedon November 12, 2019.You asked the Plan to waive the copayment forthe specialist office visit. You say that you were charged because the visit was outside the window of time covered for cataract related visits. 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 $40 copayment for services obtained from an in-network specialist or under certain circumstances, treatment by a nurse practitioner or physician's assistant or other non-physician health care professionals in a specialist's office. You have been asked to pay a $40 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows this visit was outside the global period for the cataract surgery. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment forthe specialist office visit provided on November 12, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on October 17, 2019.You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from 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 did not pre-approve the service 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 laboratory services provided on October 17, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the mammogram
You asked the Plan to waive the copayment for the mammogram. You say that you were told the mammogram
would be covered. You say you had breast cancer and that is why you continue to have the 3-D mammograms.
The Plan denied your request. The Plan says the deductible amount was removed and the Plan applied a $10
copayment towards the member's liability.
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 $10
copayment for each basic imaging service (e.g., general x-rays or ultrasound).
You have been asked to pay a $10 copayment for the mammogram. The mammogram falls within the
"Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows you
have a history of breast cancer which makes the mammogram diagnostic in nature.
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 mammogram
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the hip replacement surgery provided on
October 1, 2019.
You asked the Plan to waive the copayment for the hip replacement surgery. You say that the surgery was
never rendered because your blood pressure was too high. 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 $325
copayment for Outpatient Hospital Facility.
You have been asked to pay a $325 copayment for the hip replacement surgery. The hip replacement surgery
falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory
surgical centers" benefit category. The medical record shows you received anesthesia before the surgery was
cancelled.
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 hip replacement surgery provided on October 1, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay fortrifocal lenses (V2303) anti-reflective coating (V2750) and vision services (V2799) provided on March 8, 2019.You asked the Plan to pay forThe vision services. You say that because of the many errors with your prescriptions you do not believe that you should be charged for these visits.The Plan denied your request. The Plan says the claim processed and paid the maximum benefit allowance.The rules say that a Cost plan must disclose in writing all benefits available under the Plan. The health plan contract says that enrollees must pay any amount over the $150 eyewear allowance. The $150 allowance is allowed once every 24 months. You have been asked to pay $234 for the vision services. The vision services fall within the Vision 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 pay fortrifocal lenses (V2303) anti-reflectivecoating (V2750) and vision services (V2799) provided on March 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe electrical stimulation (G0283) and the mechanical traction therapy(97012) provided on July 18, 2019.You asked the Plan to pay forthe electrical stimulation and the mechanical traction therapy. You say that you are requesting a reconsideration of the Plan's denial.The Plan denied your request. The Plan says these services are not a covered benefit under the member's contractual policy.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. Therecords show that the services at issue are not manual manipulation of the spine.Therefore, we decided that the Plan does not have to pay forthe electrical stimulation (G0283) and the mechanical traction therapy (97012) provided on July 18, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered on October 3, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 76937 is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 76937 is ultrasound guidance for vascular access (List separately in addition to code for primary procedure). We find that CPT code 76937 is not supported in the medical record. Specifically, this is an add-on code that was not billed with a required primary procedure code. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the services rendered on October 3, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe extraction provided on November 16, 2019.You asked the Plan to pay forthe extraction. You say that you are on social security and have to pay other bills. You also say that you started paying for a dental rider and would like that to be used toward this payment.The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan'scoverage 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.The Plan says that you called on November 12, 2019 to enroll for the month of December and to have extra dental coverage. This service was provided prior to the effective date of December 1, 2019. The record shows that you signed a treatment plan acknowledging that there would be no plan payment and accepting responsibility for the cost of the treatment. Therefore, we decided that the Plan does not have to pay forthe extraction provided on November 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on August 15, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says 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 physician's services provided on August 15, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on September 25, 2019.You asked the Plan to pay forthe 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 forthe medical services provided to the enrollee by an out-of-network provider on September 25, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay forInpatient Hospital care (99221) provided November 4, 2019 to December 4, 2019. You asked the Plan to pay forthe physician services. You say that services were medically necessary.The Plan denied your request. The Plan says that the claim was incorrect.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The plan has not explained why the claim is incorrect. The plan did not furnish any clinical records to determine if the services rendered were consistent with the claim submitted. The documents submitted by the plan also appear to note that the plan approved the services, but this is unclear.Therefore, we decided that the Planhas to pay forInpatient Hospital care (99221) provided November 4, 2019 to December 4, 2019. If the Plan does not agree with our decision,they can ask us to open a case again. We only open a caseagain if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay forthe three resin-based composite (white) fillings provided from July 2, 2019 to September 3, 2019.You asked the Plan to pay forthe resin-based composites. You say that you were charged out of pocket each time you received a filling even though your plan covers fillings. You also say that you were told you would receive a refund but were later told that the provider does not owe you a refund.The Plan denied your request. The Plan says that you are responsible for the difference between the Medicare allowed amount and the provider's total charged amount.Medicare generallydoes 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, which must be presented clearly and accurately. The Plan covers certain dental services, including fillings, up to $500 per year.In this case, the Plan reduced payment for the white fillings to the amount that would be paid toward silver fillings. The Plan states that coverage for fillings of the back teeth is limited only to silver fillings and you must pay the difference if white fillings are provided. However, we find that this coverage limitation/condition is not described in your contract. We find that you would not have been reasonably aware that only silver fillings would be coveredfor back teeth. This means that the Plan did not clearly and accurately present your coverage under the dental benefit. Therefore, we decided that the Plan has to pay up to the $500 allowance for the three resin-based composite (white) fillings provided from July 2, 2019 to September 3, 2019.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter. Your complaint about being unhappy with the provideris not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forintraoperative neurophysiology monitoring (95941) provided on September 9, 2019.You asked the Plan to pay forintraoperative neurophysiology monitoring. You say that this was coded and billed correctly.The Plan denied your request. The Plan says this code is not valid for Medicare purposes.The Plan must follow Medicare rules. Medicare rules say thatproviders must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT code 95941 is not supported in the medical record. . Specifically, this code has a status indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this information, we decided that Medicare rules for coverage of intraoperative neurophysiology monitoring have not been met.Therefore, we decided that the Plan does not have to pay forintraoperative neurophysiology monitoring (95941) provided on September 9, 2019.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to waive the copayment forthe defibrillator implantation provided fromOctober 7, 2019 throughOctober 17, 2019.You asked the Plan to waive the copayment forthe defibrillator implantation. You say that the hospital charged several times for the same service.The Plan denied your request. The Plan says that the copayment applied correctly.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 enrollees must pay a $300 copayment per date of service for outpatient surgery at an outpatient hospital facility.The Plan says you must pay a $300 copayment for the defibrillator implantation. Based on the Plan contract, however, you cannot be asked to pay more than $0 for the defibrillator implantation.The outpatient surgery benefit is one copayment per date of service. The records show that two copayments were charged for outpatient surgery on the same date of service. Therefore, we decided that the Plan has to waive the copayment forthe defibrillator implantation provided from October 7, 2019 through October 17, 2019.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fordiagnostic mammogram and ultrasounds provided on October 23, 2019.You asked the Plan to waive the copayment fordiagnostic mammogram and ultrasounds. You say that this should be covered under preventative services.The Plan denied your request. The Plan says the correct copayments have 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 $50 copayment for outpatient diagnostic tests/other outpatient diagnostic tests. You have been asked to pay a $50 copayment for diagnostic mammogram and ultrasounds. The total amount you are being asked to pay is $124.50 ($50 + $50 + $24.50 = $124.50). Diagnostic mammogram and ultrasounds falls within the outpatient diagnostic tests/other outpatient diagnostic tests 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 fordiagnostic mammogram and ultrasounds provided on October 23, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the outpatient surgery services you had on
October 15, 2019.
You asked the Plan to waive the coinsurance. The Plan denied your request. The Plan says you are responsible
for the cost share.
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 10%
coinsurance for outpatient surgery services.
Review of the file shows that you were provided outpatient surgery services on October 15, 2019. You have
been asked to pay a 10% coinsurance for the services, totaling $2.58. The services fall within the outpatient
surgery 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 the outpatient surgery
services you had on October 15, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health care services provided from September 17, 2019 to September 28, 2019.
You asked the Plan to pay for home health care services. You say that you need these services. The Plan denied your request. The Plan says services from providers that do not participate in Medicare are not covered.
The Plan must follow Medicare rules. Medicare rules say that home health services are covered only when the home health agency that is providing the services to the beneficiary has in effect a valid agreement to participate in the Medicare program We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health care services have not been met. The provider you received these services from does not participate in the Medicare program. Therefore, we decided that the Plan does not have to pay for home health care services provided from September 17, 2019 to September 28, 2019.