Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the telehealth visit provided on January 21, 2021.
You asked the Plan to waive the copayment for the telehealth visit. You say that the medicine did nothing for your shoulder pain. You say that you don't want him as your pain doctor and the copayment should be waived. The Plan denied your request. The Plan says the copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $45 for each covered visit or consultation in an outpatient location with a specialist.
You have been asked to pay a $45 copayment for the telehealth visit. The telehealth visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show services were provided during the visit. 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 telehealth visit provided on January 21, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on November 20, 2020.

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 the testing is not covered.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.

The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on November 20, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for a tissue transfer (14041) provided on November 20, 2020.
You asked the Plan to pay for a tissue transfer. You say that this was billed correctly. The Plan denied your request. The Plan says that this 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 14041 is adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10.1 sq cm to 30.0 sq cm. 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 a tissue transfer. Our reviewers says that this code is supported in the records. Our physician reviewer found the operative note indicates that back cuts were made to advance the tissue. The report describes a tissue transfer not undermining. The total defect area was over 11 square centimeters. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a tissue transfer have been met. Therefore, we decided that the Plan has to pay for a tissue transfer (14041) provided on November 20, 2020.
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 for a specialist office visit provided by a
participating provider on January 19, 2021.

You asked the Plan to waive the copayment for a specialist office visit. You say that you should not have this
copayment because you did not go into the office. 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 physician/practitioner services/in-network/specialist.

You have been asked to pay a $40 copayment for a specialist office visit. Telehealth services are still subject to
the correct copayment; therefore, the correct copayment has been applied. A specialist office visit falls within
the physician/practitioner services/in-network/specialist 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 a specialist office visit provided by a participating provider on January 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the urgent care visit provided on August 12, 2020.

You asked the Plan to reduce the copayment for the urgent care visit. You say that your member card shows a $35 copayment. You say that you don't understand why you are being billed for an additional $5. The Plan denied your request. The Plan says the copayment applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for Medicare-covered urgently needed care visits.

You have been asked to pay a $40 copayment for the urgent care visit. The urgent care visit falls within the "Urgently needed 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 reduce the copayment for the urgent care visit provided on August 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown - 3/4 porcelain/ceramic (D2783) received November 9, 2020.

You asked the Plan to pay for the crown - 3/4 porcelain/ceramic (D2783). You say that you signed up for this plan under the assumption that all restorative services would be covered. The Plan denied your request. The Plan says the requested service is not covered under your 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 crown - 3/4 porcelain/ceramic (D2783) received November 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for segmental gradient pressure pneumatic appliance (CPT code E0673) and PCD (CPT Code E0675) provided to the enrollee on August 4, 2020.
You asked the Plan to pay for the DME. You say that the DME was issued to the enrollee for use during their surgery. The Plan denied your request. The Plan says this DME is not covered for this use.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home. Records show that the DME was used in a SNF or hospital. Furthermore, the PCD is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery. Therefore, we decided that the Plan does not have to pay for segmental gradient pressure pneumatic appliance (CPT code E0673) and PCD (CPT Code E0675) provided to the enrollee on August 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core buildup including any pins when required (D2950) provided January 7, 2021.
You asked the Plan to pay for the core buildup. You say that your dentist says this procedure is necessary and you do not understand why it is not covered. The Plan denied your request. The Plan says this service is not covered under your dental benefits.
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 core buildup including any pins when required (D2950) provided January 7, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional six (6) PT visits.

You asked the Plan to pre-approve additional PT visits. You say that you are not able to lift anything, and you
cannot touch your toes or sleep on your back. The Plan denied your request. The Plan says six (6) additional PT
visits are not reasonable and necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve an additional six (6) PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that based on the available records, you appear to have improved with therapy to the point of being able to manage activities of daily living including lifting groceries and driving. Further skilled therapy at this point beyond the additional six approved visits does not appear to be likely to achieve any significant improvement in your symptoms or functional status. Further utilization of the home exercise program appears appropriate after completion of the approved 26 visits. There is no documentation that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist or under the supervision of a therapist. There is no documentation that the specialized skill, knowledge and judgment of a qualified therapist is required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an additional six (6) PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve an additional six (6) PT visits.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for a transforaminal injection on January 5, 2021.

You asked the Plan to waive the co-payment for a transforaminal injection. You say that you received the procedure in a doctor's office and disagree with the high co-payment. 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 co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $370 co-payment for outpatient surgery and other medical services provided at hospital outpatient facilities.

You received a transforaminal injection on January 5, 2021, at an outpatient hospital facility. A transforaminal injection is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $370.

You have been asked to pay a $370 co-payment for a transforaminal injection. A transforaminal injection falls within the outpatient surgery and other medical 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 co-payment for a transforaminal injection on January 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for DME and related supplies provided on November 2, 2020.
You asked the Plan to waive the coinsurance for DME and related supplies. You say that the supplies came from the hospital and you did not know you would owe anything. 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 DME and related supplies. You received DME and related supplies provided on November 2, 2020. The total allowed amount is $160 and 20% of that is $32.
You have been asked to pay the total coinsurance amount of $32 for DME and related supplies. DME and related supplies fall within the DME and related 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 DME and related supplies provided on November 2, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on November 28, 2020.

You asked the Plan to pay for the ambulance services. You say that your father was treated in place by the
medics. 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 November 28, 2020. 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 provided on November 28,
2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided by an out-of-network provider on December 10, 2020.
You asked the Plan to pay for the laboratory services. You say that the medically necessary services were provided in good faith and the provider is seeking reconsideration. The Plan denied your request. The Plan says prior authorization was required but not obtained.
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 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 laboratory services provided by an out-of-network provider on December 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection services rendered on June 9, 2020.
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 64494 is not covered.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied. In this case, the MUE for CPT code 64494 is 1. You billed 2 units of this code, exceeding the MUE. 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 injection services rendered on June 9, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on June 12, 2020 by an out of network
(OON) provider.

You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and paid. The Plan
denied your request. The Plan says the referring provider is out-of-network. The Plan says that there are innetwork
providers available 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 had network providers
available who could have provided 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 lab work provided on June 12, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on January 27, 2021.

You asked the Plan to pay for the dental service. You say that this was the first time you saw this dentist. You say that you had forgotten that you had seen a dentist in 2019. You say that had you known you had to wait 3 years to see a new dentist, you would not have gone. You also say that you cannot afford to pay this bill. The Plan denied your request. The Plan says 1 comprehensive oral evaluation is covered every 3 plan years. The Plan also says that the frequency limit has been exceeded.

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 and comprehensive oral evaluation is listed as a covered service, the frequency limit has been exceeded. The record shows that the Plan paid for a comprehensive oral evaluation that you received on March 27, 2019. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on January 27, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services provided on October 21, 2020.
You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says the
Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of
election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers
attending physician services and all care unrelated to the terminal illness. Upon discharge or revocation, feefor-
service Medicare continues to cover the beneficiary through the end of the month when the beneficiary
revokes or is discharged from hospice alive.
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 ambulance services provided on October 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Fluid Flow/Fluid GF.

You asked the Plan to pre-approve Fluid Flow. You say that you believe that Fluid Flow is the best course of treatment for the enrollee. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because Fluid Flow is not Food & Drug Administration approved and not the standard of care for 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 pre-approve Fluid Flow. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is insufficient literature to support that this would be more effective than standard treatment for the enrollee's condition.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Fluid Flow have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Fluid Flow/Fluid GF.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the diagnostic mammogram provided on November 17, 2020.
You asked the Plan to waive the deductible for the diagnostic mammogram. You say that you do not believe you should be responsible for the deductible. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.
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 $750 deductible that applies towards basic imaging services. The diagnostic mammogram you asked the Plan to waive the deductible for falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible that applies towards diagnostic mammograms. Th record shows the mammogram was done due to a breast reduction which makes the mammogram diagnostic in nature.
This cost sharing is a contractual obligation that had not been met at the time the diagnostic mammogram was received on November 17, 2020. Therefore, we decided that the Plan does not have to waive the deductible for the diagnostic mammogram provided on November 17, 2020.