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

We decided that the Plan does not have to waive the coinsurance fora CPAP device and related DMEpurchased on October 11 to December 11, 2019.You asked the Plan to waive the coinsurance fora CPAP device and related DME. You say that you shouldn't be charged after not being billed for 11 months.The Plan denied your request. The Plan says the correct coinsurance 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 20% coinsurance for Medicare-covered DMEbenefits. You have been asked to pay 20% coinsurance for a CPAP device and related durable medical equipment. ACPAP device and DMEfall within the "Durable Medical Equipment (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 fora CPAP device and related DME purchased on October 11 to December 11, 2019.Your complaint about receiving delayed bills from your provideris 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 pay for the medical services provided by an out of network (OON)provider.

You asked the Plan to pay for the medical services. You say that these services were medically necessary, so they should be covered.The Plan denied your request. The Plan says unauthorized, non-plan care is not covered.

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 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe skin substitution grafts coded as 15273 and 15274 provided May 28, 2020.You asked the Plan to pay forthe skin substitution grafts. You say that please review the report and documentation you have supplied. You are requesting that this claim be reprocessed for payment.The Plan denied your request. The Plan says the service codes are not substantiated by the clinical documentation in the medical records submitted for review.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 15273 and 15274 is application of skin substitute graft to the trunk, arms or legs, for a total wound surface area greater than or equal to 100 sq cm, for each additional 100 sq cm wound surface area, or part thereof, or each additional 1% of body area of infants and children.We find that CPT code 15273 and 15274 is not supported in the medical record. Specifically, the procedure codesarenot documented in the medical records submitted.In this case, in the narrativeof the operative report,the CPT codesarenot documented.Based on this information, we decided that Medicare rules for coverage of the skin substitution grafts have not been met.Therefore, we decided that the Plan does not have to pay forthe skin substitution grafts coded as 15273 and 15274 provided May 28, 2020.
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 enrollee cannot adequately recover in a less
intensive setting than an IRF. You say that the enrollee is medically stable enough to benefit from and
participate in inpatient rehab. The Plan denied your request. The Plan says the enrollee does not meet the
requirements for approval of IRF care. The Plan says that the enrollee can safely receive the services needed in
another setting.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
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 enrollee does not require the intensity of services provided at an IRF.
Specifically, the enrollee is not shown to be able to currently perform fifteen hours per week of rehabilitative
services with regular physician evaluation. The enrollee's care needs can be met at a lower level of care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you forthe bone graft (D7950) provided on February 20, 2020.You asked the Plan to reimburse you forthe dental service. You say that you needed this service in order to prepare your gum for a dental implant. You also say that your insurance says that bone grafts are a medical procedure.The Plan denied your request. The Plan says the service you received is dental in nature. The Plan also says that the bone graft is not listed as a covered service.Medicare generally does not cover dental services. The Plan follows the same rule.Although the Plan offers a dental benefit in excess of Medicare coverage, the services you are asking the Plan to reimburse you 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 reimburse you forthe bone graft (D7950) provided on February 20, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea continuous glucose monitor.You asked the Plan to pre-approvethe requested device. You say that this device is medically necessary.The Plan denied your request. The Plan says Medicare coverage criteria are not met.The Plan must follow Medicare rules. Medicare has specific coverage criteria for this device. 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 requested device. Our reviewer says that Medicare coverage criteria are not met. Our physician reviewer found although you are prescribedfour shots per day, the records do not show you are checking your numbers as required. The medical records provided are insufficient to show that you meet all the criteria required for this device. Therecords also do not indicate why you cannot usea glucometer. Medicare coverage criteria are not met. 
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 requested device have not been met.Therefore, we decided that the Plan does not have to pre-approvea continuous glucose monitor.
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 23, 2020.
You asked the Plan to waive the copayment for an office visit. You say that you disagree with the charges because the call was only to get your test results. 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 $10 copayment for primary care provider visits. You have been asked to pay a $10 copayment for an office visit. An 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 23, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on April 17, 2019.
You asked the Plan to pay for the ambulance services. You say that once you were treated there was no need to be transported to the hospital. The Plan denied your request. The Plan says these services are not a covered benefit.
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 April 17, 2019. 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 the ambulance services provided on April 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe compression stockings identified with code A6531 rendered on October 8, 2020.You asked the Plan to pay forthe compression stockings. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. The rules say that compression stockings described by code A6531 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan.Therefore, we decided that the Plan does not have to pay forthe compression stockings identified with code A6531 rendered on October 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug provided on May 26, 2020.
You asked the Plan to waive the coinsurance for a Medicare Part B drug. You say that you only paid a copayment in the past 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 20% coinsurance for Medicare Part B prescription drugs. You received a Medicare Part B drug on May 26, 2020. The allowed amount is $1,192.32 and 20% of that is $238.46. You have been asked to pay the total coinsurance amount of $238.46 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 May 26, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecontinuation of inpatient hospital care.You asked the Plan to pre-approveinpatient hospital care. You say that the stay is medically necessary.The Plan denied yourrequest. The Plan says your Medicare inpatientbenefit will be exhausted on December 26, 2020.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient hospital care have not been met. The Plan covers up to 60 optional non-renewable lifetime reserve days. The Plan's records indicate that you have ten (10) lifetime reserve days remaining, as of December 16, 2020. Therefore, your stay will not be covered by your health plan beginning December 27, 2020.Therefore, we decided that the Plan does not have to pre-approvecontinuation of inpatient hospital care
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forinjection services received on June 15, 2020.You asked the Plan to pay forinjection services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not payable.The Plan must follow Medicare rules. Medicare rules say that no more than 3 epidural injection sessions may be reported in a 6-month period.We looked at the file and Medicare rules. Review of the file shows that you have had at least three approved injection services in January, March, and May. You have exceeded the benefit limit for injection services. Based on this information, we decided that Medicare rules for coverage of injection services have not been met.Therefore, we decided that the Plan does not have to pay forinjection services received on June 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forinitial hospital care (99222) and discharge day management (99238) received on December 28 to December 29, 2019.You asked the Plan to pay forinitial hospital care and discharge day management. You say that the Plan must complete processing for payment.The Plan denied your request. The Plan says rules for payment have not been met.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 forinitial hospital care (99222) and discharge day management (99238) received on December 28 to December 29, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services (99291) provided on April 15, 2020.
You asked the Plan to pay for the critical care services. You say that you would like reconsideration based on
the records submitted. The Plan denied your request. The Plan says the documentation does support the service
billed.
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 99291 is critical care, evaluation and management of the
critically ill or critically injured patient; first 30-74 minutes.
We find that CPT code 99291 is not supported in the record. Specifically, the documentation submitted does
not include the amount of time spent rendering critical care services. Based on this information, we decided
that Medicare rules for coverage of the critical care services have not been met. Therefore, we decided that the
Plan does not have to pay for the critical care services (99291) provided on April 15, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ambulance transport provided on May 26, 2020.You asked the Plan to waive the copayment forthe ambulance transport. 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 $265 copayment per date of service regardless of the number of ground ambulance trips.You have been asked to pay $236.26, which is less than the standard $265 copayment for the ambulance transport. The ambulance transport falls within the "Ambulance 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 forthe ambulance transport provided on May 26, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that LTACH services are medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of LTACH services.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 patient does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the patient requires that are not already available and covered at the current facility. This request for LTACH services will be considered 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 LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ambulance transport provided on July 10, 2020.You asked the Plan to waive the copayment forthe ambulance transport. You say that you did not requestto be sent via ambulance. You say that you should have been consulted about receiving a 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 $275 per one-way trip. You have been asked to pay a $275 copayment for the ambulance transport. The ambulance transport falls within the "Ambulance services" benefit category. The records show that you were transported by ambulance to the hospital. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is acontractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forthe ambulance transport provided on July 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and the filling (D2331)
provided on May 26, 2020.
You asked the Plan to pay for the dental services. You say that you broke a tooth in January and submitted the
bill and was reimbursed. You say that you broke another tooth in March and was unable to have it repaired
until May due to Covid-19. You also say that emergencies are not routine occurrences and should be reviewed
fairly and aside from the yearly amount allotted for routine care. The Plan denied your request. The Plan says
there is an annual maximum of $255 for covered dental services. The Plan says that the maximum benefit has
been exhausted.
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 benefit maximum of $255 has been
exhausted. The record shows that the Plan paid $255 for services that you received on February 12, 2020.
Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) and the filling
(D2331) provided on May 26, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay forthe reconstructive services provided on March 23, 2020.You asked the Plan to pay forthe surgical service. You say that the procedure was done and the Plan should pay this claim.The Plan denied your request. The Plan says that the procedure is not supported in the record.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 14302 is Adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm. We find that CPT code 14302 is supported in the medical record. Specifically, the record shows 72 sq cm was de-epithelized and advanced. Based on this information, we decided that Medicare rules for coverage of the tissue transferhave been met.Therefore, we decided that the Plan has to pay forthe reconstructive services provided on March 23, 2020.If the Plan does not agree with our decision,they can ask us to open a case again. We only open acase 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