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

We decided that the Plan does not have to waive the coinsurance for DME provided on September 21, 2020.
You asked the Plan to waive the coinsurance for DME. You say that you would like the charges to be lowered to a more reasonable amount. 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 on September 21, 2020. The total allowed amount is $1,716.33 and 20% of that is $343.33.
You have been asked to pay the total coinsurance amount of $343.33 for DME. DME falls 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 provided on September 21, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug provided on
December 14, 2020.
You asked the Plan to waive the coinsurance for a Medicare Part B drug. You say that you disagree with the
charges because you were just notified that your coverage changed. The Plan denied your request. The Plan
says the claim 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 Medicare Part B prescription drugs.
You received a Medicare Part B drug on December 14, 2020. The total allowed amount is $86.24 and 20% of
that is $17.25.
You have been asked to pay the total coinsurance amount of $17.25 for a Medicare Part B drug. A Medicare
Part B drug falls within the Medicare Part B prescription drugs 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 a Medicare Part B drug provided on December 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for core buildup procedures (D2950) provided on December 16, 2020.
You asked the Plan to pay for the dental services. You say that you do not believe your benefit was exhausted and you received prior approval for these services. The Plan denied your request. The Plan says the dental plan has a maximum coverage limit of $1,000. You exceeded this amount on the date of service. Payment was made up to the maximum allowance, but you are responsible for the remaining cost.
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, items or services in excess of the $1,000 annual maximum are not covered under this benefit. The Plan provided documentation of the dental services billed in 2020 and records of the Plan's payments. The Plan has paid out the full $1,000 allowed by the dental benefit for 2020. Therefore, we decided that the Plan does not have to pay for core buildup procedures (D2950) provided on December 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone growth stimulator rendered on November 25, 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 there is no valid physician order.
The Plan must follow Medicare rules. The rules say that a supplier must have an order from the treating physician before dispensing any DMEPOS item to a beneficiary. We looked at the file and Medicare rules. There is no valid physician order for the DME. 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 bone growth stimulator rendered on November 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyeglasses (V2020, V2200) purchased on February 10,
2021.
You asked the Plan to pay for the eyeglasses. You say that this should be covered up to $175 per your benefit
allowance. The Plan denied your request. The Plan says you last received eyeglasses on February 24, 2020,
which is less than one year before the date in question. This benefit is administered on a rolling calendar year
since your last date of service, so your eyewear benefit was exhausted until February 24, 2021.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan covers eyewear once a year from the last date of service.
We looked at the file and the Plan's rules. Your last eyewear purchase was less than a full year before the date
in question. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not
been met. Therefore, we decided that the Plan does not have to pay for the eyeglasses (V2020, V2200)
purchased on February 10, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient care provided from April 6, 2019, to April 9, 2019, and billed with DRG 872.
You asked the Plan to pay for inpatient care billed with DRG 872. You say that this was billed with the correct DRG. The Plan denied your request. The Plan says the sepsis diagnosis (A41.9) is not supported.
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 872, septicemia or severe sepsis without mechanical ventilation greater than 96 hours without 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 872. Our reviewer says that DRG 872 is not supported in the records. Our physician reviewer found the provided records do not show sufficient evidence of sepsis being present as there was no sign of end organ damage. 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 April 6, 2019, to April 9, 2019, and billed with DRG 872.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for calibrator solution/chips billed with Healthcare Common Procedure Coding System (HCPCS) code A4256 for dates of service February 19 - May 19, 2020.
You asked the Plan to pay for the calibrator solution/chips billed with HCPCS code A4256. You say that the documentation provided is sufficient and shows that the items in dispute were delivered to the enrollee. The Plan denied your request. The Plan says that the documentation submitted did not include an itemized shipping/billing invoice to indicate the specific supplies, or proof of delivery.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The rules also say that acceptable proof of delivery requires that the supplier's record be linked to the delivery service record by some clear method like the delivery service's package identification number or supplier's invoice number for the package sent to the beneficiary. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the Plan has not substantiated their denial reason that the documentation submitted did not include an itemized shipping/billing invoice to indicate the specific supplies, or proof of delivery. We found that a detailed invoice was provided which was linked to the delivery confirmation for the items in dispute. Therefore, we decided that the Plan has to pay for calibrator solution/chips billed with Healthcare Common Procedure Coding System (HCPCS) code A4256 for dates of service February 19 - May 19, 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for additional supplies, materials, and clinical staff time (99072) provided on December 10, 2020.
You asked the Plan to pay for additional supplies, materials, and clinical staff time. You say that this was billed according to public health emergency guidelines. The Plan denied your request. The Plan says this is not separately payable.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 99072 is not supported in the medical record. Specifically, this code has a status code of B. Payment for this service is always bundled into payment for other services. Based on this information, we decided that Medicare rules for coverage of additional supplies, materials, and clinical staff time have not been met. Therefore, we decided that the Plan does not have to pay for additional supplies, materials, and clinical staff time (99072) provided on December 10, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for laboratory services provided on December 21, 2020.

You asked the Plan to waive the co-payment for the laboratory services. You say that the labs were taken at the same place as the office visit. You say that you were not aware there would be a separate cost. The Plan denied your request. The Plan says the co-payment applied correctly.

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 $10 for Medicare-covered laboratory tests.

You have been asked to pay a $10 co-payment for the laboratory services. The laboratory services fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. Outpatient diagnostic tests are considered a separate service. 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 laboratory services provided on December 21, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room services provided January 12, 2021.

You asked the Plan to waive the copayment for the emergency services. You say that you had to go to the hospital because you suffer from hypertension and had very high blood pressure. You were not admitted and was sent home late once your blood pressure had stabilized. The Plan denied your request. The Plan says this claim was processed and the correct copayment was applied per the Evidence of Coverage.

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 copayment for emergency care for Emergency care. 

You have been asked to pay $50 copayment for emergency care for the emergency services. the emergency services fall 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 services provided January 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the requested care is a necessity for you. The Plan denied your request. The Plan says rules for IRF care have 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 that 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 were admitted for cervical spine surgery. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program.

You do require physical and occupational therapy but there is no documented need for an intensive 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 IRF admission and services.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on September 17, 2020.

You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says that for hospice services and for services that are covered by Medicare Part A or B and are related to your terminal prognosis, Original Medicare (rather than our plan) will pay for your hospice services and any Part A and
Part B services related to your terminal prognosis. While you are in the hospice program, your hospice provider will bill Original Medicare for the consultation services that Original Medicare pays for on this date of service.

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 physician's services provided on September 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for crown - porcelain/ceramic (D2740) and the crown - porcelain fused to predominantly base metal (D2751) received January 4, 2021.
You asked the Plan to pay an additional amount for the crowns. You say that the Plan should pay based off the services received. The Plan denied your request. The Plan says if a method of treatment is more costly than is customarily provided, benefits will be paid on the least costly method of treatment, and you will be responsible for the remaining balance.
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 payment is excess of that which is covered under this benefit. If a method of treatment is more costly than is customarily provided, benefits will be paid on the least costly method of treatment, and you will be responsible for the remaining balance. 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 pay an additional amount for crown - porcelain/ceramic (D2740) and the crown - porcelain fused to predominantly base metal (D2751) received January 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a wheelchair ramp, seat lift mechanism, and sales tax
provided from October 26, 2020, to November 11, 2020.
You asked the Plan to pay for wheelchair ramp, seat lift, and sales tax. You say that both of these items were
needed for your daily life. The Plan denied your request. The Plan says the denial of payment for these items is
correct, because a wheelchair ramp is not covered by Medicare and the Plan has not received an order for the
lift chair or support for its medical necessity.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate
and needed for use inside the home. The rules state that coverage of a seat lift mechanism requires a standard
written order from the treating practitioner documenting that all appropriate therapeutic methods have been
tried and failed to enable the beneficiary to transfer from a chair to a standing position. The rules state that
Medicare does not make separate payment for sales taxes.
The wheelchair ramp at issue in this appeal is for use outside of the home. Although this item may be helpful,
neither Medicare nor the Plan covers equipment for use outside the home. No order was submitted for the seat
lift mechanism you are requesting payment for. In addition, Medicare does not make separate payment for sales
taxes. Therefore, we decided that the Plan does not have to pay for a wheelchair ramp, seat lift mechanism, and
sales tax provided from October 26, 2020, to November 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-share for the periodic oral evaluation (D0120), cleaning (D1110) and bitewing x-rays (D0274) provided on December 10, 2020, by an out-of-network provider.
You asked the Plan to waive the cost-share for the dental services. You say that you had seen this provider before and did not realize they were out-of-network. This bill is a financial hardship. The Plan denied your request. The Plan says this provider is out-of-network and the cost-sharing was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 50% coinsurance for each periodic oral exam, bitewing x-ray, and dental cleaning provided out-of-network. Benefits received out-of-network are subject to any in-network benefit maximums, limitations, and/or exclusions. You may be billed by the out-of-network provider for any amount greater than the payment made by the Plan to the provider. You have been asked to pay 50% coinsurance for the dental services, plus the amount billed that exceeds the payment made by the Plan. The provider billed the Plan $240 for all three services. The Plan's allowed amount for these services totals $94. In-network providers have agreed to be paid the Plan's rate, but out-of-network providers do not have this agreement, so you are responsible for the difference between the providers rate and what the Plan allows for these services ($240 - $94 = $146). In addition, you are responsible for 50% coinsurance of the allowed amount when these services are provided out-of-network ($94 x 50% coinsurance = $47). You are responsible for a total of $193 ($146 + $47 = $193) for these 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 cost-share for the periodic oral evaluation (D0120), cleaning (D1110) and bitewing x-rays (D0274) provided on December 10, 2020, by an out-of-network provider.
Your complaint about confusion regarding the location and network status of this provider 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient office visit (99213) provided January 25, 2021.
You asked the Plan to waive the copayment for the office visit. You say that this was not an office visit as you did not see your PCP. No service was rendered to you, but you are being charged. The Plan denied your request. The Plan says the claim was processed and the correct cost share was applied per the Evidence of Coverage.
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 telehealth visit or consultation in an outpatient location with your PCP or other primary care provider.
You have been asked to pay $10 for the office visit. The office visit falls within the Physician/Practitioner services, including doctor's office 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 outpatient office visit (99213) provided January 25, 2021.