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

We decided that the Plan does not have to pre-approve the semi-electric hospital bed (E0260).
You asked the Plan to pre-approve the semi-electric hospital bed. You say that it is your understanding that
CHF is an acceptable reason for a bed that raises to be approved. The appointment to meet with the doctor to
discuss this request was cancelled due to the corona virus. The Plan denied your request. The Plan says this
enrollee does not meet the criteria for coverage of a semi-electric hospital bed.
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered
medically necessary when the patient:
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or
2. Requires attachments which can only be attached to a hospital bed; AND
3. Requires frequent changes in body position and/or has an immediate need for a change in body position.
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 semi-electric hospital bed. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found review of the provided medical records does not reveal documentation that
the enrollee's condition requires positioning of the body in ways not feasible in an ordinary bed, that the
enrollee's condition requires frequent changes in body position or that there is a need for immediate changes in
body position. The records do not reveal documentation that the enrollee's condition requires special
attachments that cannot be fixed and used on an ordinary bed and 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 the semi-electric hospital bed have not been met. Therefore, we decided that the
Plan does not have to pre-approve the semi-electric hospital bed (E0260).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the durable medical equipment (DME) provided on October 3, 2019.
You asked the Plan to pay for the DME. 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 when conducting a review of a covered DME item ordered by a physician, the Plan shall ensure that the physician saw the enrollee (including through the appropriate use of telehealth) and conducted a face-to-face assessment. We looked at the file and Medicare rules. The file does not contain documentation showing that the face-to-face encounter included information supporting the enrollee was evaluated or treated for a condition that supports the DME ordered. The file does not document that the face-to-face encounter was made prior to the written order for the conditions listed on the written order. Therefore, we decided that the Plan does not have to pay for the durable medical equipment (DME) provided on October 3, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for orthotic devices (L1851, L2397, L0650) provided October 9, 2019.
You asked the Plan to pay for the orthotic devices. You say that the items were medically necessary. The Plan denied your request. The Plan says rules for telehealth were not met, so the items are not covered.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. The provided records do not show an established relationship between the enrollee and the prescribing provider. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the non-covered visit are likewise non-covered. Therefore, we decided that the Plan does not have to pay for orthotic devices (L1851, L2397, L0650) provided October 9, 2019.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the panoramic x-ray provided on February 17, 2020.
You asked the Plan to pay for the panoramic x-ray. You say that you want to appeal your films not being paid.
The Plan denied your request. The Plan says that the maximum benefit for this time period or occurrence has
been reached.
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 panoramic x-ray by a contract provider. The file does not show that the Plan
provided notice that the panoramic x-ray would not be covered. Under Medicare rules, this means the
panoramic x-ray is considered approved by the Plan. The EOC does not clearly state the limitations of
panoramic x-rays. You reasonably believed that this would be covered under the two x-rays you are limited to
per year. Therefore, we decided that the Plan has to pay for the panoramic x-ray provided on February 17,
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided from July 15. 2019 to August
15, 2019.
You asked the Plan to pay for the chiropractic services. The Plan denied your request. The Plan says you must
receive care from in-network providers with the exception of emergency or urgent care, dialysis while
temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which
requires prior authorization from the plan.
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 did not pre-approve the
chiropractic services. We found no exception that would require the Plan to pay for these services. Therefore,
we decided that the Plan does not have to pay for chiropractic services provided from July 15. 2019 to August
15, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation, bitewings, prophylaxis, and panoramic x-ray provided on December 12, 2019 by an OON provider.
You asked the Plan to pay for the comprehensive oral evaluation, bitewings, prophylaxis, and panoramic x-ray. You say that you were told that you would have to pay for the services from this treating provider and then submit for reimbursement. The Plan denied your request. The Plan says the treating provider is OON. The Plan also says that you self-referred OON, and your plan does not cover non-emergency services by OON providers.
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 covered when they are received OON. The records show that the Plan only advised you that an organization determination must be authorized to see an OON provider. There is no record that you received approval for this provider prior to the services being rendered. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation, bitewings, prophylaxis, and panoramic x-ray provided on December 12, 2019 by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the debridement services provided on January 13, 2020.
You asked the Plan to waive the deductible for the debridement services. You say that the services you received should be considered routine services based on the 2018 Annual Notice of Changes booklet. 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. Your contract with the Plan says that there is a $150 deductible that applies towards debridement services. The debridement services you asked the Plan to waive the deductible for falls within the "Podiatry Services" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $150 deductible that applies towards in-network debridement services. The record shows that debridement is considered a surgical procedure.
This cost sharing is a contractual obligation that had not been met at the time the debridement services were received on January 13, 2020. Therefore, we decided that the Plan does not have to waive the deductible for the debridement services provided on January 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation, complete series of intraoral x-rays, and prophylaxis provided on December 17, 2019 by an OON provider.
You asked the Plan to pay for the comprehensive oral evaluation, complete series of intraoral x-rays, and prophylaxis. You say that you contacted the Plan and were told that these services would be covered at 100%. The Plan denied your request. The Plan says the treating provider is an OON provider. The Plan also says that these services were paid at 100% of the Plan's allowed amount and you are responsible for the difference in the provider's submitted fee and the allowed amount for these 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, you are responsible for the difference between the billed amount and allowed amount when the services are received OON. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation, complete series of intraoral x-rays, and prophylaxis provided on December 17, 2019 by an OON provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic radiology services provided on January 7, 2020.
You asked the Plan to waive the copayment for the diagnostic radiology services. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received diagnostic radiology services on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.
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 $100 copayment for each Medicare-covered radiological diagnostic service. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received diagnostic radiology services on January 7, 2020. You have been asked to pay a $67.43 copayment for the diagnostic radiology services, which is less than the $100 contracted copayment amount. The diagnostic radiology services fall within the Outpatient diagnostic tests 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 diagnostic radiology services provided on January 7, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on June 27, 2019.
You asked the Plan to waive the copayment for the emergency room visit. You say that you do not agree with the services performed during your emergency room visit. 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 $90 copayment per emergency room visit within or outside the services area. You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls within the "Emergency care" benefit category. The medical record shows you received a computed tomography (CT) scan during your emergency room visit.
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 visit provided on June 27, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the oxygen concentrator (E1390) provided on January 15, 2020.
You asked the Plan to pay for the oxygen concentrator. You say that the concentrator was medically necessary. The Plan denied your request. The Plan says there were network providers available.
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 item at issue in this appeal. The Plan did not pre-approve the item at issue. We found no exception that would require the Plan to pay for these items. Therefore, we decided that the Plan does not have to pay for the oxygen concentrator (E1390) provided on January 15, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for an ultrasound of the heart provided on November 6, 2019.
You asked the Plan to waive the copayments for an ultrasound of the heart. You say that you paid $50 already and disagree with being charged a second copayment. 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 each x-ray and ultrasound. You have been asked to pay a $50 copayment for an ultrasound of the heart. An ultrasound of the heart 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 copayments for an ultrasound of the heart provided on November 6, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the repair of a broken complete maxillary denture base
(D5512) and addition of three teeth to an existing partial denture (D5650 x3) provided on January 21, 2020.
You asked the Plan to pay for the repair of a broken complete maxillary denture base and addition of three
teeth to the existing partial denture. You say that these services were pre-approved and nothing in the preauthorization
made any reference to the services not being covered in 2020. The Plan denied your request. The
Plan says these services are clearly excluded from your 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. The record shows that the pre-authorization states the following: This
pre-authorization of allowances is not a guarantee of payment and is subject to the following conditions: 3.
Allowances indicated below may vary if plan benefits change prior to performance of these services. 4. The
patient must be eligible for benefits when the services are deemed incurred. An expense is incurred when a
service is performed. Therefore, we decided that the Plan does not have to pay for the repair of a broken
complete maxillary denture base (D5512) and addition of three teeth to an existing partial denture (D5650 x3)
provided on January 21, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for neuropsychological testing provided from December 3, 2019 to December 12, 2019.
You asked the Plan to waive the coinsurance for neuropsychological testing. You say that you disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees must pay 20% coinsurance for non-radiological diagnostic services. The enrollee received neuropsychological testing from December 3, 2019 to December 12, 2019. Therefore, they are responsible to pay the total amount of $191.48, which is less than the 20% coinsurance amount. The enrollee has been asked to pay $191.48 for neuropsychological testing. Neuropsychological testing falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for neuropsychological testing provided from December 3, 2019 to December 12, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for outpatient mental health services provided
from November 5, 2019 to December 20, 2019.
You asked the Plan to waive the copayments for outpatient mental health services. You say that you feel that
you should owe a $20 copayment per each visit. 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 $40
copayment for outpatient mental health care.
You received outpatient mental health services from November 5, 2019 to December 20, 2019 for a total of 4
visits. Therefore, you are responsible to pay a $40 copayment per each visit. The total amount you owe is:
$160.
You have been asked to pay the total copayment amount of $160 for outpatient mental health services.
Outpatient mental health services fall within the outpatient mental health 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 copayments for outpatient mental health services provided from November 5, 2019
to December 20, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the re-cement or re-bond of a crown provided on January 30, 2020.
You asked the Plan to pay for the re-cement or re-bond of a crown. You say that you believe this procedure falls within the same category as cleaning, bitewing x-rays, and other preventive services. The Plan denied your request. The Plan says this service is not a covered benefit.
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. The Plan only covers preventive dental services. Recementing of a crown is not considered preventive and is excluded from coverage. Therefore, we decided that the Plan does not have to pay for the re-cement or re-bond of a crown provided on January 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided from July 16, 2019 to December 12, 2019 by an OON provider.
You asked the Plan to pay for the dental services. You say that you were told that you would have to pay for the services from this treating provider and then submit for reimbursement. You also say that the Plan representative said that your OON coverage was approved, but because it was filed incorrectly, your claim was rejected. The Plan denied your request. The Plan says the treating provider is OON. The Plan also says that you self-referred OON, and your plan does not cover non-emergency services by OON providers.
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 covered when they are received OON. The records show that the Plan only advised you that an organization determination must be authorized to see an OON provider. There is no record that you received approval for this provider prior to the services being rendered. Therefore, we decided that the Plan does not have to pay for the dental services provided from July 16, 2019 to December 12, 2019 by an OON provider.