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

We decided that the Plan has to reimburse you for the mouth guard (D7999) provided August 29, 2017.
You asked the Plan to reimburse you for the mouth guard. You say that the mouth guard should not be billed as
a surgery and should be covered. The Plan denied your request. The Plan says that the service is not covered.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract
provider are considered approved by the plan unless notice is provided that the services will not be covered.
The Plan follows these rules.
You were referred for the mouth guard by a contract provider. The file does not show that the Plan provided
notice that the mouth guard would not be covered. Under Medicare rules, this means the mouth guard is
considered approved by the Plan. Therefore, we decided that the Plan has to reimburse you for the mouth guard
(D7999) provided August 29, 2017.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care provided on November 12, 2020.
You asked the Plan to pay for the subsequent hospital care. You say that the enrollee's hospice benefits had been revoked. 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. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on November 11, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care provided on November 12, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient care provided from January 15, 2019, to January 18, 2019, and billed with DRG 391.
You asked the Plan to pay for inpatient care billed with DRG 391. You say that the billed DRG was correct. The Plan denied your request. The Plan says the diagnosis of pneumonia is not supported, so the DRG was changed from 391 to 392.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services provided with DRG 391, esophagitis, gastroenteritis and miscellaneous digestive disorders with major complications or comorbidities. 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 inpatient care billed with DRG 391. Our reviewer says that the billed DRG is not supported. Our physician reviewer found pneumonia was diagnosed, but not supported in the records. Imaging
showed clear lungs without infiltrate or other finding suggestive of a pneumonia. As the diagnosis of pneumonia was not evidenced from imaging or other findings, DRG 391 is not supported by the records.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient care provided from January 15, 2019, to January 18, 2019, and billed with DRG 391.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bridge for teeth # 13, 14, and 15.
You asked the Plan to pre-approve the bridge. You say that you were not aware that the Plan only permits to have front bridges. You say that you have no other option. You say also say that your dentist and 2 specialists said you would need a bridge. You also say that you thought it would be covered. The Plan denied your request. The Plan says bridges are only covered for front teeth. The Plan says that there is no coverage for the replacement of a missing posterior tooth with a fixed prosthesis.
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, a bridge to replace a posterior tooth is not among those covered under this benefit. The record shows that requested bridge is for the replacement of tooth # 14. Tooth # 14 is a posterior tooth and therefore is not covered. Therefore, we decided that the Plan does not have to pre-approve a bridge for teeth # 13, 14, and 15.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound provided on November 24, 2020.
You asked the Plan to waive the copayment for the ultrasound. You say that you were told it would be a zero copayment. You say that the Plan should fully cover the charge. 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 $125 copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a physician's office or at a free-standing facility. You have been asked to pay $118.09, which is less than the standard $125 copayment for the ultrasound. The ultrasound falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ultrasound provided on November 24, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (CPT 80307 and HCPCS G0483) provided to the enrollee on June 3, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the denied codes remain 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. We find that CPT code 80307 and HCPCS G0483 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's office (POS 11). 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 pay for drug testing services (CPT 80307 and HCPCS G0483) provided to the enrollee on June 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for chemodenervation provided on November 16, 2020.

You asked the Plan to waive the co-payment for chemodenervation. You say that you only owed a $35 co-payment in the past and disagree with the additional charges. 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 $100 co-payment for outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers.

The record shows that you received chemodenervation at an outpatient hospital facility on November 16, 2020. Chemodenervation is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $100 co-payment.

You have been asked to pay a $100 co-payment for chemodenervation. Chemodenervation 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 chemodenervation provided on November 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuromuscular stimulator described by current procedural terminology (CPT) code E0745 provided on December 12, 2020.
You asked the Plan to pay for CPT code E0745. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must confirm that Medicare coverage criteria have been met. We looked at the file and Medicare rules. In this case, there were no records provided confirming that the neuromuscular stimulator (E0475) was provided on December 12, 2020. Therefore, we decided that the Plan does not have to pay for the neuromuscular stimulator described by current procedural terminology (CPT) code E0745 provided on December 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
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 enrollee does not meet the criteria for coverage.
The Plan must follow Medicare rules. Medicare rules say that a therapeutic CGM is covered when specific criteria are met. We looked at the file and Medicare rules. The records show that the enrollee is not testing blood sugar levels four or more times per day. 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-approve a Freestyle Libre continuous glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone replacement graft for ridge preservation (D7953) provided on December 8, 2020.
You asked the Plan to pay for the bone replacement graft. You say that you would like this service to be covered. The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan'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 bone replacement graft for ridge preservation (D7953) provided on December 8, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible and coinsurance for laboratory services provided on December 7, 2020.
You asked the Plan to waive the deductible and coinsurance for laboratory services. You say that the laboratory services were part of your annual physical and you should not 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. Your contract with the Plan says that there is a $250 deductible. Your contract with the Plan also says that after the $250 deductible has been met, enrollee's must pay 20% coinsurance for laboratory services. You received laboratory services on December 7, 2020. Laboratory services are not included in annual wellness exams. Therefore, you are responsible to pay your share of the cost-sharing charges. The record shows that you had only paid $178.88 toward the $250 deductible prior to receiving the services. Therefore, you are responsible to pay the remaining deductible balance of $71.12. Now that the $250 deductible has been met, you are also responsible to pay 20% coinsurance on the difference between the allowed amount and the amount that applied toward the deductible. $82.26 (allowed amount) - $71.12 (deductible amount) = $11.14 and 20% of that is $2.23. The total amount you owe is: $71.12 + $2.23 = $73.35. The item or service you asked the Plan to waive the deductible and coinsurance for falls within the benefit category outpatient diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $250 deductible and 20% coinsurance for laboratory services. This cost sharing is a contractual obligation that had not been met at the time laboratory services were received on December 7, 2020. Therefore, we decided that the Plan does not have to waive the deductible and coinsurance for laboratory services provided on December 7, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (HCPCS G0483) provided to the enrollee on August 18, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that HCPCS code G0483 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's office (POS 11). 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 pay for drug testing services (HCPCS G0483) provided to the enrollee on August 18, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional 10 physical therapy (PT) visits and 8 occupational therapy (OT) visits.

You asked the Plan to pre-approve the home health services. You say that you are experiencing pain in your right shoulder. You say that you have to use your left arm to maneuver your right arm a little. You say that you are not comfortable, and your right shoulder bothers you all day. You also say that you think that therapy can help. The Plan denied your request. The Plan says you are having a temporary period of weakness, which is expected to improve as you resume normal activities. The Plan says there are no other home care skilled needs identified at this time. The Plan also says that the 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 the home health services. Our reviewer says that the additional PT and OT visits are not medically necessary.

Our physician reviewer found the provided documentation does not support that you require additional skilled rehab services to provide treatment that is medically necessary. The reviewer found that you do not require additional skilled rehab services 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.

The reviewer found that you have been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. The reviewer found that you are independent with a home exercise program. Therefore, the reviewer found that the requested home health services 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 home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve an additional 10 physical therapy (PT) visits and 8 occupational therapy (OT) visits.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy to be provided by the out-of-network provider.
You asked the Plan to pre-approve the physical therapy to be provided by the out-of-network provider. You say that this provider specializes in Parkinson's disease and knows the enrollee. The Plan denied your request. The Plan says that the Plan does have physical therapist who specialize in patients with movement disorders such as Parkinson's disease.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physical therapy to be provided by the out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee has been in the hospital for
14 days and needs to be transitioned to LTACH for long-term weaning. The Plan denied your request. The Plan
says the denial of authorization for LTACH care is correct.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
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 LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee is receiving acute hospital care which has not been denied. The
documentation does not support that the enrollee requires services at the LTACH that are not available at the
acute care hospital where she is currently receiving care. The documentation does not support that an additional
25 days of hospitalization are reasonable expected for the enrollee.
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 LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a core build up (D2950), a crown (D2750), and a periodic oral evaluation (D0120) provided from September 30, 2019, through December 9, 2019.
You asked the Plan to pay for a core build up, a crown, and a periodic oral evaluation. You say that you want the Plan to pay for these services. The Plan denied your request. The Plan says records indicate you were not enrolled in the Dental Rider at the time the services were rendered, and therefore, the services at issue are not covered.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for a core build up (D2950), a crown (D2750), and a periodic oral evaluation (D0120) provided from September 30, 2019, through December 9, 2019.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a full mask for a continuous positive airway pressure (CPAP) machine.
You asked the Plan to pre-approve CPAP face mask. You say that you are appealing this denial. The Plan denied your request. The Plan says that the denial of authorization for this item is correct, because there is no documentation that your current mask cannot meet your needs.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. 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 CPAP face mask. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found you have moderate obstructive sleep apnea and are being treated with CPAP. The usual reason for requesting a full face mask is mouth breathing during sleep, which is a reasonable request for a patient being treated with CPAP. The medical order for this item is documented and there are no specific Medicare criteria requiring additional documentation. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CPAP face mask have been met. Therefore, we decided that the Plan has to pre-approve a full mask for a continuous positive airway pressure (CPAP) machine.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care provided on December 15, 2020.
You asked the Plan to waive the copayment for emergency care. You say that you did not receive care and disagree with the charges. 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 $50 copayment for emergency care. The medical records show that you received emergency care on December 15, 2020. Therefore, you are responsible to pay the $50 copayment. You have been asked to pay a $50 copayment for emergency care. Emergency care 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 emergency care provided on December 15, 2020.