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

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that Medicare will not pay for dental services. Dental services are items and services involving the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Benefit Policy Manual, Chapter 15, Section 150.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract says that the Plan covers certain dental services as a supplemental (extra) benefit. The Plan contract does not list the prefabricated post and core and crown and core buildup as covered benefits. You can find this information on page 90 of the 2021 Evidence of Coverage (EOC).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient hospital visit provided by a participating provider on February 27, 2020.

You asked the Plan to waive the copayment for an outpatient hospital visit. You say that you do not agree with this copayment. 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 $225 copayment for outpatient hospital services/procedure. 

You have been asked to pay $110.73 which is less than your copayment amount of $225 for an outpatient hospital visit. The correct copayment has been applied to the services that were provided in an outpatient hospital. An outpatient hospital visit fall within the outpatient hospital services/procedure 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 an outpatient hospital visit provided by a participating provider on February 27, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 10 additional physical therapy (PT) home health visits.
You asked the Plan to pre-approve 10 additional PT home health visits. You say that the services are necessary.
The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not
been met.
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 10 additional PT home health visits.
Our reviewer says that the services are not medically necessary. Our physician reviewer found the records do
not support that you require additional skilled services at home to improve your overall condition or level of
function.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of 10 additional PT home health visits have not been met. Therefore, we decided
that the Plan does not have to pre-approve 10 additional physical therapy (PT) home health visits.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy provided from
August 3, 2020, through September 4, 2020.

You asked the Plan to waive the copayment for physical therapy. You say that you believe you were deceived by the orthopedic and rehabilitation doctor because you were told that you would be covered under your Plan and you were not told about the copays when you started the therapy. The Plan denied your request. The Plan says the correct copayments were applied to the claims.

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 Outpatient Rehabilitation Services.

You have been asked to pay a $25 copayment for physical therapy. Physical therapy falls within the Outpatient Rehabilitation Services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for physical therapy provided from August 3, 2020, through September 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the deep sedation services (dental codes D9222 and D9223) and surgical removal of residual tooth roots (dental code D7250) provided on May 11, 2021.

You asked the Plan to pay for the deep sedation services and removal of residual tooth roots. You say that these procedures were medically necessary prior to heart surgery. The Plan denied your request. The Plan says these services are not covered. The Plan also says that the member did not contact them prior to the services to ensure they would be covered.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the deep sedation services (dental codes D9222 and D9223) and surgical removal of residual tooth roots (dental code D7250) provided on May 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a miscellaneous vision service (V2799) provided on March 27, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for a miscellaneous vision service. You say that you were told that you could go to an out-of-network provider of choice and then submit a claim. The Plan denied your request. The Plan says services should be received from network providers who are listed in the provider directory.
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. The records provided for review do not show that the services at issue were urgent or emergent. 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 a miscellaneous vision service (V2799) provided on March 27, 2021, by an out-of-network (OON) provider
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the fluouroscopy procedure you had at an
outpatient hospital facility on April 8, 2021.

You asked the Plan to waive the copayment for the fluouroscopy procedure. You say that you did not have a
kidney stone, so you were told there would be no charge. The Plan denied your request. The Plan says you
were charged this copayment 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 $325
copayment for outpatient hospital facility visits.

The medical records from this procedure show that you did undergo a fluoroscopy procedure on this date even
though you did not have the extracorporeal shockwave lithotripsy you were originally scheduled for. You have
been asked to pay a $325 copayment for the fluouroscopy procedure. The fluouroscopy procedure falls within
the outpatient hospital facility visits 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 fluouroscopy procedure you had at an
outpatient hospital facility on April 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve  Active Care bed system.
You asked the Plan to pre-approve  Active Care bed system. You say that the item is necessary. The Plan denied your request. The Plan says the item has deluxe features that are not primarily medical in nature. Therefore, coverage criteria have not been met.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve  Active Care bed system
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
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 IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and related services (99213) provided on
April 9, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the office visit. You say that this was the provider you were told to see when you
joined this plan. The Plan denied your request. The Plan says this provider is out-of-network. There is no
referral on file for these services, nor were they pre-approved or urgent. Therefore, payment is denied.
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 the office visit and related services (99213)
provided on April 9, 2021 by an out-of-network (OON) provider.
Your complaint about a potential miscommunication from the Plan regarding the identity or network status of
your assigned primary care provider is not a valid appeal for medical coverage. You say that this is the provider
you were directed to see when you enrolled in this Plan. Plan documentation shows that this provider is out-ofnetwork.
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 waive to copayment for the injection provided on December 8, 2020.
You asked the Plan to waive to copayment for the injection. You say that you were told you would not have a copayment. 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $225 copayment per visit for outpatient surgery or procedure. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the standard $225 copayment for the injection.
You have been asked to pay a $186.61 copayment for the injection. The injection falls within the "Outpatient hospital services" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. The record shows you received the injection in an outpatient location. 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 to copayment for the injection provided on December 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral - periapical first radiographic image (D0220) and intraoral - periapical each additional radiographic image (D0230) provided May 7, 2021.
You asked the Plan to pay for the intraoral x-rays. You say that you had the same service last year and it was covered. The Plan denied your request. The Plan says these services are not covered under your 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 intraoral - periapical first radiographic image (D0220) and intraoral - periapical each additional radiographic image (D0230) provided May 7, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered by Part B Medicare.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. The file shows that the Plan has approved these services under the enrollee's Part D drug benefit. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on February 5, 2021.
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 G0481 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 G0481 is definitive drug testing, 8-14 drug classes. We find that CPT code G0481 is not supported in the medical record. Specifically, there is no documentation of testing of 8-14 drug classes. 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 drug testing rendered on February 5, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on December 4, 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 20999 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 20999 is unlisted procedure, musculoskeletal system, general. We find that CPT code 20999 is not supported in the medical record. Specifically, the operative report does not
include documentation of an unlisted musculoskeletal system procedure. 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 surgical services rendered on December 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0673, E0675) provided August 27, 2020.
You asked the Plan to pay for the pneumatic compression device. You say that the pneumatic compression device was medically necessary. The Plan denied your request. The Plan says the item was used during an inpatient procedure. Payment for this item is included in the facility claim.
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 pneumatic compression device was used in a hospital. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0673, E0675) provided August 27, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport provided on March 7, 2021.
You asked the Plan to pay for ambulance response and treatment, no transport. You say that you were visiting a friend when you did not feel well, and the ambulance was called. You say that you are a diabetic and required your insulin, so you refused transport to the hospital because it was quicker to go home and take your insulin. The Plan denied your request. The Plan says there is no coverage for ambulance services when there is no transport.
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 March 7, 2021. 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 ambulance response and treatment, no transport provided on March 7, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the lab services you had on December 24, 2020.
You asked the Plan to waive the copayment for the lab services. You say that you do not believe that the Plan has paid the correct amount towards these lab services. The Plan denied your request. The Plan says you were charged this copayment 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 $5 copayment for lab tests. You have been asked to pay a $5 copayment for the lab services. Because you did not have molecular and predisposed genetic testing, the $5 copayment applies. 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 lab services you had on December 24, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation.
You asked the Plan to pre-approve additional routine transportation. You say that the additional transportation is needed. The Plan denied your request. The Plan says the benefit has been exhausted.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 48 one-way transportation trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation.