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

We decided that the Plan does not have to waive the copayment for the office visit and eye ultrasounds provided on February 3, 2020.You asked the Plan to waive the copayment for the office visit and eye ultrasounds. You say that you were advised the doctor is in-network. You say that the Plan should pay for all the costs.The Plan denied your request. The Plan says the copayments 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 $30 copayment for each Tier 1 specialist visit and a $40 copayment for each Tier 1 basic imaging service (x-rays or ultrasounds). You have been asked to pay a total of $70 for the office visit and eye ultrasounds. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The eye ultrasounds fall 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 office visit and eye ultrasounds provided on February 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.You asked the Plan to pre-approve incontinence supplies. You say that your are immobile.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items.Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 2 standard power wheelchair.You asked the Plan to pre-approve a Group 2 standard power wheelchair. You say that the enrollee needs a Group 2 standard power wheelchair.The Plan denied your request. The Plan says a Group 2 standard power wheelchair is not medically necessary.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. 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 a Group 2 standard power wheelchair. Our reviewer says that a Group 2 standard power wheelchair is not medically necessary. Our physician reviewer the enrollee is not noted to have inability to utilize a lesser device (lightweight manual wheelchair, standard manual wheelchair, or use of a lesser power mobility device such as a group 1 chair).  Therefore, this request is 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 a Group 2 standard power wheelchair have not been met.Therefore, we decided that the Plan does not have to pre-approve a Group 2 standard power wheelchair.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on May 30, 2019 to July 31, 2019 by an out of network (OON) provider.You asked the Plan to pay for the outpatient mental health services.You say that you would like reconsideration because the services were medically necessary and you are the preferred provider of the facility.The Plan denied your request. The Plan says the psychotherapy services were rendered by a non-Plan provider, did not meet emergency criteria, were not ordered by a Plan provider and were not authorized in compliance with the Plan's authorization process.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 has network providers available who can provide 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 medical services provided on May 30, 2019 to July 31, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for toe surgery (28160, 28308) received from a provider that has opted out of Medicare on February 13, 2019.You asked the Plan to pay for toe surgery. You say that you were told you would be reimbursed 60% of these charges.The Plan denied your request. The Plan says services received from opt-out providers are not covered.The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.The services at issue in this appeal were provided in a non-urgent, non-emergent situation. The provider of these services has opted out of the Medicare program. The file shows that the provider entered into a private contract with you regarding payment.Therefore, we decided that the Plan does not have to pay for toe surgery (28160, 28308) received from a provider that has opted out of Medicare on February 13, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the extraction (D7210) of tooth # 17, the fixed partial denture sectioning (D9120), and the drugs or medicaments (D9630) provided on October 31, 2019. You also asked the Plan to waive the coinsurance for the extraction(D7210) of tooth # 18 provided on October 31, 2019.You asked the Plan to reimburse you for the dental services. You say that it does not make sense that only 1 of the extractions you received is covered. You say the 2 teeth were next to each other. You also say that the teeth had to be separated from a bridge.The Plan denied your request. The Plan says that 1 extraction per year is covered with a 50% coinsurance. The Plan says that the frequency limit for extractions was exceeded. The Plan also says fixed partial denture sectioning and the drugs or medicaments are not 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 and extractions are a covered service, the frequency limit has been exceeded. The record shows the Plan paid for the extraction of tooth # 18 that you received on October 31, 2019, you are responsible for the cost sharing amount. This is a contractual obligation you agreed to when you enrolled in the Plan's dental coverage. Additionally, the fixed partial denture sectioning and drugs or medicaments are not covered services. Therefore, we decided that the Plan does not have to reimburse you forthe extraction (D7210) of tooth # 17, the fixed partial denture sectioning (D9120), and the drugs or medicaments (D9630) provided on October 31, 2019. You also asked the Plan to waive the coinsurance for the extraction (D7210) of tooth # 18 provided on October 31, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Lifetime Fitness recumbent exercise bike.You asked the Plan to pre-approve a Lifetime Fitness recumbent exercise bike. You say that your doctor wants you to have the equipment right away because you are unable to go to physical therapy.The Plan denied your request. The Plan says a recumbent exercise bike does not meet the definition of Durable Medical Equipment.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. Home exercise/ physical therapy equipment that can be obtained without a prescription is considered to be an over the counter supply, is not considered DME, and is therefore, ineligible for coverage.Therefore, we decided that the Plan does not have to pre-approve a Lifetime Fitness recumbent exercise bike.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided on April 19, 2019.
You asked the Plan to waive the copayment for office visit. You say that you saw a nurse practitioner, so you feel it should be covered as a primary care provider. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.
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 $40 copayment for specialist visit. The rendering provider was a urology specialist; therefore, the specialist visit copayment applies to this visit. You have been asked to pay $40 copayment for office visit. 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 an office visit provided on April 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids (V5261) ear mold/insert (V5264) dispensing fee (V5160) purchased January 27, 2020.
You asked the Plan to pay for the hearing aids. You say that you are writing to ask for review your claim for hearing aids. The audiologist and clinic involved is part of the medical group that is in-network with the plan.. The Plan denied your request. The Plan says hearing aids ordered through providers other than the Plan are not covered.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when ordered through providers other than the Plan are not covered. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids (V5261) ear mold/insert (V5264) dispensing fee (V5160) purchased January 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the frames (V2020) and single vision lens (V2100) and anti-reflective lens (V2750) purchased on January 28, 2020.You asked the Plan to pay for the vision services. You say that you are appealing the denial of payment for vision lenses purchased from a non-participating provider.The Plan denied your request. The Plan says enrollee's must receive their vision services from an in-network provider.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 these services when purchased from an out of network provider.We looked at the file and the Plan's rules. Vision services must be provided by an in-network provider. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met.Therefore, we decided that the Plan does not have to pay for the frames (V2020) and single vision lens (V2100) and anti-reflective lens (V2750) purchased on January 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an all lower extremity prostheses, flex-walk system or
equal (L5981).
You asked the Plan to pre-approve an all lower extremity prostheses, flex-walk system or equal. You say that
you need this prostheses and additions to walk unassisted. The Plan denied your request. The Plan says the
notes do not support the need for the requested K3 foot.
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 an all lower extremity prostheses, flexwalk
system or equal. Our reviewer says that the requested item is not considered medically reasonable and
necessary in this case. Our physician reviewer found you are now status post Syme's amputation, right ankle.
A Syme prosthesis is now requested. You live alone and are cognitively intact and able to use a prosthesis.
You are a current K3 level ambulator and want to be able to walk unlimited distances. There is no documented
failure to respond to a traditional prosthesis. This particular device with a suspension / flex-walk system is not
supported as a result, as it is a convenience item if there is no failure to respond to a lesser device. As such,
this request is 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 an all lower extremity prostheses, flex-walk system or equal have not been met.
Therefore, we decided that the Plan does not have to pre-approve an all lower extremity prostheses, flex-walk
system or equal.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye injection provided on February 28,
2020.
You asked the Plan to waive the copayment for the eye injection. You say that you had an injection and no real
surgery. You say you have been receiving these injections and have never received a same day surgery
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 $350
copayment for each Medicare-covered outpatient surgery in an ambulatory surgical center or hospital
outpatient facility.
You have been asked to pay a $350 copayment for the eye injection. The eye injection falls within the
"Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical
centers" benefit category. The record shows the eye injection is considered a surgical procedure. 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 eye injection provided on February 28, 2020.
Our decision is only about the 2020 services. If you have any questions about prior years billing, please contact
the plan directly.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital services provided
from October 20, 2019 through October 23, 2019.
You asked the Plan to waive the copayment for the inpatient hospital services. The Plan denied your request.
The Plan says the copayment applies per your 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 a $275
copayment per day for days 1-5 of Inpatient hospital care.
You have been asked to pay a $825 copayment for the inpatient hospital services. The inpatient hospital
services fall within the days 1-5 of 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 services provided from October 20, 2019 through October 23,
2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for moderate sedation services (99152) provided on November
13, 2019.
You asked the Plan to pay for moderate sedation services. You say that you would like reconsideration based
on the records submitted. The Plan denied your request. The Plan says the medical records submitted do not
include documentation of the presence of an independent trained observer to assist in the monitoring of the
patient's level of consciousness and physiological status.
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 99152 is moderate sedation services provided by the
same physician or other qualified health care professional performing the diagnostic or therapeutic service that
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age
5 years or older.
We find that CPT code 99152 is not supported in the record. Specifically, the record does not indicate the
presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness
and physiological status. Based on this information, we decided that Medicare rules for coverage of moderate
sedation services have not been met. Therefore, we decided that the Plan does not have to pay for moderate
sedation services (99152) provided on November 13, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wheelchair ramp.
You asked the Plan to pre-approve a wheelchair ramp. You say that you need a ramp to enter and exit your
house. The Plan denied your request. The Plan says wheelchair ramps are not primarily medical in nature.
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. Medicare does
not cover home modifications. Also, the item 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. Therefore,
we decided that the Plan does not have to pre-approve a wheelchair ramp.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency room services provided December 30, 2019.
You asked the Plan to waive the copayment for the emergency room services. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct cost sharing was 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 $90 copayment for Emergency Care. You have been asked to pay a $90 copayment for the emergency room services. The emergency room 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 emergency room services provided December 30, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the cardiac rehabilitation rendered from August 12, 2019 to November 1, 2019.
You asked the Plan to waive the copayments for these services. You say that the provider told you there would be no charges. The Plan denied your request. The Plan says the copayments were 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 $20 copayment for each visit for cardiac rehabilitation services.
Review of the file shows that you received cardiac rehab from August 12, 2019 to November 1, 2019. Per the contract with the Plan, there is a $20 copayment for each visit for cardiac rehabilitation services. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. However, the Medicare allowed amount for these services was $15.30 per visit. Given that the allowed amount was less than the $20 copayment, you have been asked to pay $15.30 per visit for these services.
Therefore, we decided that the Plan does not have to waive the copayments for the cardiac rehabilitation rendered from August 12, 2019 to November 1, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prefabricated post and core in addition to crown (D2954) and a mandibular partial denture (D5226).
You asked the Plan to pre-approve the prefabricated post and core and mandibular partial denture. You say that you need these services done in order to eat better. The Plan denied your request. The Plan says these services are excluded from your dental coverage.
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 pre-approve a prefabricated post and core in addition to crown (D2954) and a mandibular partial denture (D5226).