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

We decided that the Plan does not have to pre-approve a Group 2 power wheelchair and accessories.
You asked the Plan to pre-approve a Group 2 power wheelchair and accessories. You say that you need a power wheelchair. The Plan denied your request. The Plan says you are able to ambulate and perform you MRADLs within the home.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The file shows that you do not have a mobility deficit that impairs your participation in MRADLs and your condition can be improved by a walker, cane or manual wheelchair. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 2 power wheelchair and accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on November 5, 2019.
You asked the Plan to waive the copayment for the office visit. You say that the visit was not necessary. You say that there should not be a fee. 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 $10 for each covered visit or consultation in an outpatient location with your PCP or other primary care physician. You have been asked to pay a $10 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show that the office visit was for a follow up for atrial fibrillation. 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 office visit provided on November 5, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core build up (D2950).
You asked the Plan to pre-approve the dental services. You say that it is medically necessary for the core build up to be provided in order to get the crown. The Plan denied your request. The Plan says core build up is not listed as a covered 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. Though the Plan offers a dental benefit in excess of Medicare coverage, core build up is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core build up (D2950).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from November 13, 2019 to November 15, 2019.
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you cannot afford this copayment. 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 $372 copayment for each day for days 1-5 per admission. You have been asked to pay a $372 copayment for each day of the inpatient hospital stay. ($372 x 2 days = $744). The inpatient hospital stay falls within the "Inpatient hospital care" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from November 13, 2019 to November 15, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lightweight wheelchair, elevating leg rests, and accessories.
You asked the Plan to pre-approve a lightweight wheelchair, elevating leg rests, and accessories. You say that the enrollee is dependent upon a wheelchair. The Plan denied your request. The Plan says the record shows the enrollee can self-propel 50% and there is no evidence to support the need for elevating leg rests.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. There is no face-to-face document supporting a lightweight wheelchair and accessories. Based on this information, we decided that Medicare rules for coverage of a lightweight wheelchair, elevating leg rests, and accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a lightweight wheelchair, elevating leg rests, and accessories.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Revitive Medic Circulation Booster.You asked the Plan to pre-approve Revitive Medic Circulation Booster. You say that the Revitive was misrepresented as a foot massager. It does not massage the foot, it increases blood flow and helps the muscles grow. This would help your veins and leg muscles and is beneficial to you.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and Revitive Medic Circulation Booster is an OTC item.Therefore, we decided that the Plan does not have to pre-approve Revitive Medic Circulation Booster.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bath/shower chair.
You asked the Plan to pre-approve a bath/shower chair. You say that you need a shower chair. The Plan denied
your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are
not primarily medical in nature.
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this
item. Therefore, we decided that the Plan does not have to pre-approve a bath/shower chair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve retainer crowns (D6740) for teeth # 4, 6, 12, and 14, and pontics (D6245) for teeth # 5 and 13.
You asked the Plan to pre-approve the dental services. You say that you need these bridges. You say that without them, it is more and more difficult to eat properly. The Plan denied your request. The Plan says retainer crowns and pontics are not listed as covered services.
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, retainer crowns and pontics are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve retainer crowns (D6740) for teeth # 4, 6, 12, and 14, and pontics (D6245) for teeth # 5 and 13.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea skilled nursing facility (SNF) admission for the enrollee.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the admission is not medically necessary.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 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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the hospital with abnormal weight loss, chronic back pain, right diabetic foot infection and osteomyelitis and chronic cholecystitis with indwelling cholecystostomy tube. He was effectively treated for pain and has a wound vac on his foot. He received physical therapy in the hospital and needs varied assistance with activities of daily living. He has no skilled therapy needs. He has skilled nursing needs but does not require skilled nursing on a daily basis. As a practical matter, the enrollee does not require the necessary services on an inpatient basis at the SNF level of care. We looked at this physician's review, the file, and Medicare rules. 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 pre-approvea skilled nursing facility (SNF) admission for the enrollee.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on October 14, 2019.
You asked the Plan to waive the copayment for the emergency room visit. You say that you should not be responsible for the copayment. 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 $25 copayment for each Medicare-covered emergency room visit. You have been asked to pay a $25 copayment for the emergency room visit. The emergency room visit falls within the "Emergency care" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the emergency room visit provided on October 14, 2019.
Your complaint about your misdiagnosis during the emergency room visit 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that the enrollee would be home alone and needs assistance with wound care. The Plan denied your request. The Plan says the treatment needed can be provided in a lower level of care. The Plan says that the enrollee's needs are custodial in nature and that skilled care is not required.
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 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications and insulin, had stable vital signs, was treated for sepsis, and received diuresis. The enrollee had uncomplicated wound care to his buttocks. The enrollee received physical therapy in the acute hospital and was at an independent to supervision level with functional mobility, including gait to 600 feet with no assistive device. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMEMS device.
You asked the Plan to pre-approve the CardioMEMS device. You say that the records provided support the medical necessity of a CardioMEMS device. The Plan denied your request. The Plan says the requested device is not medically necessary.
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 the CardioMEMS device. Our reviewer says that a CardioMEMS device is not considered medically reasonable and necessary in this case. Our physician reviewer found therapy change based on data obtained from a CardioMEMS device has been demonstrated in only one trial to help reduce hospital readmission compared to standard medical therapy. Moreover, concerns have been raised about potential bias in this trial calling into question the results. Therefore, the efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and not recommended in current guidelines for the treatment of heart failure. The device is considered experimental or investigational. 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 CardioMEMS device have not been met. Therefore, we decided that the Plan does not have to pre-approve a CardioMEMS device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the full amount forthe periodic oral evaluation (D0120), prophylaxis (D1110), and the bitewing x-rays (D0274) provided on August 14, 2019.You asked the Plan to pay the full amount forthe dental services. You say that when you saw the provider in February 2019 they were in network and your claim was paid. You say that you went 6 months later and received a claim saying that the provider was out of network. You also say that you were never informed that the provider was no longer in network.The Plan denied your request. The Plan says the provider in this case is not a network provider. The Plan says there is no record that you called to verify the providers network status prior to your appointment. The Plan also says it is your responsibility to verify provider status prior to every appointment as a provider can leave or join the network at any time.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 the services you received are listed as covered, the services were received out of network and are subject to a higher cost share amount.  CPT CodeBilled AmountAllowed AmountCoinsurance(50%)Amount Above AllowableYour ResponsibilityD0120$58$37$18.50$21$39.50D1110$105$68$34$37$71D0274$70$45$22.50$25$47.50TOTAL:$158Therefore, we decided that the Plan does not have to pay the full amount forthe periodic oral evaluation (D0120), prophylaxis (D1110), and the bitewing x-rays (D0274) provided on August 14, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for psychotherapy provided by the physician, from August 20, 2019 to August 27, 2019.
You asked the Plan to waive the copayments for psychotherapy. You say that you were told that you would not owe a copayment. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for each individual visit for outpatient mental health care. You received individual psychotherapy on August 20, 2019 and August 27, 2019 for a total of 2 visits. Therefore, you are responsible to pay a $40 copayment per each visit. The total amount you owe is: $80. You have been asked to pay the total copayment amount of $80 for psychotherapy. Psychotherapy falls within the outpatient mental health care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for psychotherapy provided by the physician, from August 20, 2019 to August 27, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for radiation therapy provided by the physician on November 27, 2019.
You asked the Plan to waive the copayment for radiation therapy. You say that you feel the charges are too high and cannot afford them. The Plan denied your request. The Plan says the claims were processed correctly, and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $60 copayment for each radiation therapy service. You have been asked to pay a $60 copayment for radiation therapy. Radiation therapy 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 radiation therapy provided by the physician on November 27, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient hospital observation services from October 14, 2019 through October 16, 2019 provided by an in-network provider.
You asked the Plan to waive the copayment for outpatient hospital observation services. You say that the hospital is in-network and you should not be billed a copayment. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 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 outpatient hospital observation services from October 14, 2019 through October 16, 2019 provided by an in-network provider. You met your $1,000 deductible prior to the services; therefore, you are asked to pay a $300 copayment for the in-network observation services. 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 outpatient hospital observation services from October 14, 2019 through October 16, 2019 provided by an in-network provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for an emergency department visit (99282) provided September 12, 2019.
You asked the Plan to pay for an emergency department visit. You say that the services should be billed on the same claim. The Plan denied your request. The Plan says a missing modifier is not allowing this service to pay.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
In this case, we have confirmed that code 99283 has a bundled relationship with code 99282 and cannot be paid as billed. This code cannot be paid as a separate line item unless billed with an appropriate modifier. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for an emergency department visit (99282) provided September 12, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve oral exam (D0150) and surgical extraction (D7210) to be provided by an oral surgeon.
You asked the Plan to pre-approve the dental services. You say that you do not believe that this denial is justified when both of the general dentists concluded that a dental surgeon must perform the extraction due to potential medical complications due to your age. The Plan denied your request. The Plan says this service is not a covered 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. The plan contract specifically says services must be performed by a participating general dentist. 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 pre-approve oral exam (D0150) and surgical extraction (D7210) to be provided by an oral surgeon.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for psychotherapy services provided by the physician on November 2, 2018
You asked the Plan to waive the coinsurance for psychotherapy services. You say that you were told you were covered. 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 50% coinsurance for out-of-network outpatient mental health care. You received psychotherapy services on November 2, 2018 from an out-of-network provider. Therefore, you are responsible to pay your share of the out-of-network cost-sharing charges. The allowed amount is $377.53 and 50% of that is $188.76. You have been asked to pay the total coinsurance amount of $188.76 for psychotherapy service. Psychotherapy service falls within the outpatient mental health care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for psychotherapy services provided by the physician on November 2, 2018