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

We decided that the Plan does not have to pay for the pontic (D6240) and two retainer crowns (D6750) provided on March 10, 2020. You asked the Plan to pay for the pontic and retainer crowns. You say that you assumed your dental coverage was increased due to hearing an advertisement stating Medicare was increasing dental coverage. The Plan denied your request. The Plan says these services are not covered benefits. The Plan also says that you did not elect to purchase an optional supplemental 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. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the pontic (D6240) and two retainer crowns (D6750) provided on March 10, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the head collar, seat lift mechanism, non-electric, any type (E0629) and 
delivery/set up/dispensing (A9901) purchased by the enrollee from August 16, 2019 through August 21, 2019. 
 
You asked the Plan to pay for the DME. You say that you and the enrollee both contacted the Plan prior to 
services being rendered and were advised the DME items were covered. The Plan denied your request. The 
Plan says that the items are not covered under Medicare or the Health Plan. 
 
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. Review of the file shows that the head collar that was provided on August 21, 
2019 which was billed with code 99199 as this was included in the appeal letter. We were not provided with 
any information regarding this DME, this was provided in-network and the Plan was aware of this issue in the 
beginning of the year. Therefore,  the plan should reimburse the total purchase price since they never got a code 
from the network provider. 
 
For the seat lift, it does not appear that anyone informed you are the enrollee that only the mechanism would be 
covered nor did they tell the enrollee that they could only go to certain providers. Therefore, the Plan will have 
to pay the full amount for the DME. Therefore, we decided that the Plan has to pay for the head collar, seat lift 
mechanism, non-electric, any type (E0629) and delivery/set up/dispensing (A9901) purchased by the enrollee 
from August 16, 2019 through August 21, 2019.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit provided on February 12, 2020. 
 
You asked the Plan to pay for the outpatient office visit. You say that the diagnosis used is not the same as the 
enrollee's hospice diagnosis. The Plan denied your request. The Plan says Original Medicare would be 
responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal 
condition. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the outpatient office visit provided on February 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a hearing aid evaluation (V5020) provided October 30, 2019.
You asked the Plan to pay for the hearing aid evaluation. You say that the hearing exam should be covered.
The Plan denied your request. The Plan says the benefit was already exhausted on the expense of the hearing
aid itself. There was no hearing services allowance left to cover the evaluation.
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 provides an
annual $500 allowance for hearing aids and hearing aid evaluations.
We looked at the file, and the Plan's rules. By time the claim was submitted for the hearing exam, the hearing
aid benefit was already expended towards the cost of the hearing aid. Based on this information, we decided
that the Plan's rules for coverage of the hearing aid evaluation have not been met. Therefore, we decided that
the Plan does not have to pay for a hearing aid evaluation (V5020) provided October 30, 2019.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says you are physically capable of self-administering medications. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found in this case, the 
documentation doesn't support that you require skilled nursing services or skilled rehab services to provide 
treatment that is medically necessary. You do not require skilled nursing to effectively provide treatment, care, 
and/or services in order to improve your condition, perform a maintenance program to maintain your condition 
and/or prevent deterioration. There is no documentation that supports that you require 120 skilled nursing 
visits. 
 
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-approve home health services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for static progressive stretch knee device, extension and/or 
flexion, with or without range of motion adjustment, includes all components and accessories (E1811) provided 
to the enrollee from October 8, 2019 through November 8, 2019. 
 
You asked the Plan to pay for the DME. You say that the claim should be paid. The Plan denied your request. 
The Plan says this device is not a Medicare covered benefit for any use other than directly after knee joint 
replacement surgery. The Plan states this is a non-covered service and it is not a benefit when ordered by either 
a contracted or a non-contracted provider. 
 
The Plan must follow Medicare rules. The rules say that CPM devices are covered only for patients who have 
received total knee replacement surgery. 
 
This device is not a Medicare covered benefit for any use other than directly after knee joint replacement 
surgery. Therefore, we decided that the Plan does not have to pay for static progressive stretch knee device, 
extension and/or flexion, with or without range of motion adjustment, includes all components and accessories 
(E1811) provided to the enrollee from October 8, 2019 through November 8, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient hospital services provided on March 5, 2020.
You asked the Plan to pay for the outpatient hospital services. The Plan denied your request. The Plan says the enrollee 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 outpatient hospital services provided on March 5, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve four additional home health physical therapy visits for 
the enrollee. 
 
You asked the Plan to pre-approve the additional visits. You say that this is medically necessary. The Plan 
denied your request. The Plan says the medical necessity cannot be determined without an updated 
reassessment of the enrollee's status and progress towards treatment goals. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 additional visits. Our reviewer says 
that the requested additional visits are not medically reasonable or necessary. Our physician reviewer found in 
this case, the documentation doesn't support that the enrollee requires skilled nursing services or skilled rehab 
services to provide treatment that is medically necessary. The enrollee does not require skilled nursing or rehab 
services to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, 
perform a maintenance program to maintain the patient's condition and/or prevent deterioration. There is no 
indication that further physical therapy is required to meet the short or long term goals to restore function. The 
enrollee has been authorized for 12 sessions of physical therapy and the additional 4 sessions are not medically 
necessary. 
 
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 additional visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve four additional home health physical therapy visits for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on November 6, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the medical services. You say that you would like reconsideration because this provider has been your attending physician for years and you would like a review for continuity of care. The Plan denied your request. The Plan says this provider is outside your network of providers and prior authorization was not obtained 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 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 November 6, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the services rendered from January 1, 2020 to April 3, 2020.
You asked the Plan to waive the cost sharing for these services. You say that the services were a follow up to a 2019 inpatient hospital stay and should apply towards the 2019 deductible. The Plan denied your request. The Plan says the cost sharing was 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 there is $500 yearly deductible for point-of-service covered medical services, a $75 copayment for high-tech Medicare-covered diagnostic radiology services, such as CT, MRI, MRA, and PET, and a $35 copayment for each specialist visit for Medicare-covered benefits.
Review of the file shows that you received service on January 1, 2020; January 6, 2020; and January 25, 2020 from an out-of-network provider. These services fall within the point-of-service benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $500 yearly deductible for point-of-service covered medical services. This cost sharing is a contractual obligation that had not been met at the time these services were received on January 1, 2020; January 6, 2020; and January 25, 2020.
The file shows that you received specialist services on January 25, 2020. You have been asked to pay a $35 copayment for these services. These services fall within the specialist visit for Medicare-covered benefits benefit category. This cost sharing is a contractual obligation that you agreed to pay when you enrolled in the Plan. This means that you have been asked to pay the correct amount for these services based on the contract with the Plan.
The file shows that you received high-tech radiology services on April 3, 2020. You have been asked to pay a $75 copayment for these services. These services fall within the high-tech Medicare-covered diagnostic radiology services benefit category. This cost sharing is a contractual obligation that you agreed to pay when
you enrolled in the Plan. This means that you have been asked to pay the correct amount for these services based on the contract with the Plan.
These services were performed in the year 2020, so the 2020 cost sharing benefits apply. Therefore, we decided that the Plan does not have to waive the cost sharing for the services rendered from January 1, 2020 to April 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve abutment supported porcelain fused to metal crowns 
(D6059) for tooth #'s 4, 5, 7, 19, and 30. 
 
You asked the Plan to pre-approve the abutment supported porcelain fused to metal crowns. You say that your 
dentist was able to provide the Plan with a copy of the needed x-ray. You also say that there seems to be a 
technical issue. The Plan denied your request. The Plan says the service is not medically necessary. 
 
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 the abutment 
supported porcelain fused to metal crowns when the services are medically necessary and reasonable.  
 
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 abutment supported porcelain fused 
to metal crowns. Our reviewer says that the abutment supported porcelain fused to metal crowns (D6059) for 
tooth #'s 4, 5, 7, 19, and 30 are not medically necessary. Our physician reviewer found tooth #'s 4, 5, 7, 19, and 
30 have no implants placed in the bone. The requested implant crowns (D6059) do not correspond to any 
placed implant fixtures in the jaw. Without implant fixtures being placed in the bone, there would be no 
necessity for the implant supported crowns as is being requested. Our reviewer also found that given the 
current supplied information, there is no support for any implant crowns (D6059) on tooth #'s 4, 5, 7, 19, and 
30. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the abutment supported porcelain fused to metal crowns have not been met. 
Therefore, we decided that the Plan does not have to pre-approve abutment supported porcelain fused to metal 
crowns (D6059) for tooth #'s 4, 5, 7, 19, and 30.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for all services provided in a chiropractic setting on March 31, 2020.
You asked the Plan to pay for these services. You say that this service should be covered by the Plan. You say that you paid $40 But the Plan only paid $2. The Plan denied your request. The Plan says Medicare only covers services billed by a chiropractic office that relate to manual manipulation of the spine. All other services such as physical therapy or other modalities provided in a chiropractic office are not covered.
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 physical therapy and hot and cold packs provided in a chiropractic setting on March 31, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom made foot orthotics, shoe inserts, (L3000). 
 
You asked the Plan to pre-approve foot orthotics. You say that you are appealing the denial of the insert molds 
for your shoes because you will be returning back to work soon and it hurts when you walk due to plantar 
fasciitis. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve custom made foot orthotics, shoe 
inserts, (L3000).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the morphometric analysis services coded 88377 provided on April 9, 2020.
You asked the Plan to pay for the morphometric analysis services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the billed services are not separately payable.
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, we have confirmed that code 88377 for the morphometric analysis service has a bundled relationship with code 81445 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the morphometric analysis services coded 88377 provided on April 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for oxygen concentrators, and portable gas
provided from March 2, 2020 through May 2, 2020.
You asked the Plan to waive the coinsurance for the DME. You say that you do not have any money left from
social security to pay the provider. The Plan denied your request. The Plan says the claims were processed
accordingly with your 2020 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance).
Review of the file show that you received the DME from March 2, 2020 through May 2, 2020. You are asked
to pay 20% coinsurance for the DME. Your EOC states, "enrollees must pay 20% coinsurance for DME and
related supplies." 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 oxygen concentrators, and
portable gas provided from March 2, 2020 through May 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist services rendered on April 15, 2019.
You asked the Plan to waive the copayment for these services. You say that you saw the nurse practitioner and paid $5. The Plan denied your request. The Plan says the copayment was 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 $40 copayment for each covered specialist office visit.
Review of the file shows that you received specialist services on April 15, 2019. You have been asked to pay a $40 copayment for these services. These services fall within the covered specialist office visit 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. The cost sharing applies whether you see a physician or a nurse practitioner. The file shows that you have paid $5 towards this copayment and now owe $35. Therefore, we decided that the Plan does not have to waive the copayment for the specialist services rendered on April 15, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergent ambulance transportation provided to the 
enrollee on December 23, 2019. 
 
You asked the Plan to pay for non-emergent ambulance transportation. You say that the claim should be paid. 
The Plan denied your request. The Plan says routine ambulance requires a prior authorization for dual 
advantage flex plan. The Plan states they will only cover ambulance/ambulate hospital discharge without an 
authorization. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of non-emergent ambulance transportation have not been met. The claim was denied because the 
provider  failed to notify the Plan regarding services and subsequently an authorization was not issued. 
Therefore, we decided that the Plan does not have to pay for non-emergent ambulance transportation provided 
to the enrollee on December 23, 2019.