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

We decided that the Plan does not have to pay for the intraoral x-rays provided on March 24, 2021.

You asked the Plan to pay for the intraoral x-rays. You say that you were never told these x-rays were not covered and you refuse to pay this amount. The Plan denied your request. The Plan says intraoral x-rays are 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. Therefore, we decided that the Plan does not have to pay for the intraoral x-rays provided on March 24, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (29823) provided January 29, 2021.

You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed services.

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 29823 is Arthroscopy, shoulder, surgical; debridement, extensive.

We find that CPT code 29823 is not supported in the medical record. Specifically, the operative report did not detail an extensive debridement. Based on this information, we decided that Medicare rules for coverage of the surgical services have not been met. Therefore, we decided that the Plan does not have to pay for surgical services (29823) provided January 29, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound rendered on December 29, 2020.

You asked the Plan to waive the copayment for these services. You say that you disagree with the charges. The Plan denied your request. The Plan says the copayment 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 a $110 copayment for each Medicare-covered radiological diagnostic service, not including x-rays.

Review of the file shows that you received an ultrasound on December 29, 2020. Per the contract with the Plan, there is a $110 copayment for each Medicare-covered radiological diagnostic service, not including x-rays. 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 $65.11. Given that the allowed amount was less than the $110 copayment, you have been asked to pay $65.11 for these services.

Therefore, we decided that the Plan does not have to waive the copayment for the ultrasound rendered on December 29, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the emergency room services provided on January 22, 2021.

You asked the Plan to waive the copay for the services provided. You say that your insurance is supposed to cover it. The Plan denied your request. The Plan says the copay is your responsibility.

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 copay for emergency care. 

You have been asked to pay a $50 copay for the services provided. the services provided falls within the emergency care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copay for the emergency room services provided on January 22, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for chemotherapy treatment provided on December 9 to December 30, 2020.

You asked the Plan to waive the coinsurance for chemotherapy treatment. You say that you cannot afford the charge at issue. 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 15% coinsurance for Medicare-covered Part B prescription drugs, including chemotherapy drugs. 

You have been asked to pay $1,156.14, or 15% of the Medicare-allowed charge of $7,707.65, for chemotherapy treatment. Chemotherapy treatment 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 chemotherapy treatment provided on December 9 to December 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient psychiatric care provided on November 12, 2020 by an out-of-network (OON) provider.

You asked the Plan to pay for the inpatient psychiatric care. You say that due to circumstances outside of your control, you were unable to successfully obtain an authorization for the enrollee's services. You believe the enrollee met medical necessity and that their services should be covered. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

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 had network providers available who could have provided 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 inpatient psychiatric care provided on November 12, 2020 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient surgical services rendered on December 21, 2020.

You asked the Plan to waive the copayment for these services. You say that you disagree with the charges. The Plan denied your request. The Plan says the copayment 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 a $250 copayment for Medicare-covered surgery or other services provided to you at an ambulatory surgical center or outpatient hospital.

Review of the file shows that you received outpatient surgical services on December 21, 2020. You have been asked to pay a $250 copayment for these services. These services fall within the Medicare-covered surgery or other services provided to you at an ambulatory surgical center or outpatient hospital 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 surgical services rendered on December 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the underarm crutch rendered on November 27, 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 the services are not covered.

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid. 

In this case, the MUE for CPT code E0114 is 1. You billed 2 units of this code, exceeding the MUE. 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 underarm crutch rendered on November 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services provided on November 9, 2020 to November 18, 2020 by an out-of-network (OON) provider.

You asked the Plan to pay for the OON services. The Plan denied your request. The Plan says services rendered by non-participating providers require prior authorization.

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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the chiropractic services at issue in this appeal. The Plan did not pre-approve the services at issue. 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 the chiropractic services provided on November 9, 2020 to November 18, 2020 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the endodontic therapy (root canal) and cone beam computed tomography rendered on February 9, 2021.

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 the services are not covered.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the endodontic therapy (root canal) and cone beam computed tomography rendered on February 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional payment for the crown - porcelain/ceramic (D2740), intraoral - periapical first radiographic image (D0220), and intraoral - periapical each additional radiographic image (D0230) provided January 28, 2021.

You asked the Plan to provide additional payment for the crown and periapical x-rays. You say that you would not have agreed to the services if you had known how expensive it was. The Plan denied your request. The Plan says the out-of-network services were covered according to your dental benefits.

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. The Plan covers the crown and periapical x-rays up to the Plan's contracted allowed amount. If you see a dentist outside of the dental network, you may be charged for your coinsurance plus the difference between the allowed amount and the total cost billed by the provider. 

We looked at the file and Medicare rules. The Plan provided documentation showing that the Plan covered 100% of the allowed amount for the periapical x-rays and 50% of the allowed amount for the crown. You were responsible for 50% of the allowed amount of the crown plus the difference between the allowed amount and the total cost billed by the out-of-network dentist for all the services at issue. Therefore, we decided that the Plan does not have to provide additional payment for the crown - porcelain/ceramic (D2740), intraoral - periapical first radiographic image (D0220), and intraoral - periapical each additional radiographic image (D0230) provided January 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the pneumatic compression device and appliances provided
on September 9, 2020.

You asked the Plan to pay for the pneumatic compression device (E0675) and appliances (E0673). You say that
the device was prescribed by the doctor and used during surgery. The Plan denied your request. The Plan says
Medicare does not pay any supplier other than the facility or hospital for services furnished to the beneficiary
while an inpatient.

The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the
purpose of prevention of venous thromboembolism (E0675) is a preventive service.

We looked at the file and Medicare rules. Payment for this service would have been included under the facility
claim. Based on this information we decided that Medicare rules for coverage of the PCD have not been met.

Specifically, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pay for the pneumatic compression device and appliances provided on September 9, 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 intensive inpatient rehabilitation is the best option for your recovery. The Plan denied your request. The Plan says criteria for admission to an IRF are not met; the necessary services can be provided at another level of care.

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 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. Medically necessary services can be provided in a different 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from May 7, 2020, to June 23, 2020.

You asked the Plan to pay for home health services. You say that this was billed correctly. The Plan denied your request. The Plan says these services must be billed in 30-day periods.

The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. For periods of care beginning on or after January 1, 2020, the duration of a period is 30 days. 

We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the date range billed on this claim exceeds 30 days, which is the duration of a period for services provided after January 1, 2020. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from May 7, 2020, to June 23, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the chest x-ray (71046) and the laboratory
services (80061, 80053, 81001) provided February 11, 2021.

You asked the Plan to waive the copayment for the diagnostic services. You say that you have never paid for
this before and do not think you should have to pay now. You paid the office copay as you normally do and this
should be the only copay paid as on out of pocket expense. The Plan denied your request. The Plan says the
claim was processed with the correct cost share 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 $195
copay for Medicare covered diagnostic tests and procedures in an outpatient hospital setting and $50 for
laboratory services in an outpatient hospital setting for Outpatient diagnostic tests and therapeutic services and supplies. 

You have been asked to pay $98.21 ($83.48 + $14.73) for the diagnostic services. Since the allowed amounts were less than the copayment amount, you are responsible for the lesser amount. the diagnostic services 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 chest x-ray (71046) and the laboratory services (80061, 80053, 81001) provided February 11, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-transport ambulance service (A0429), provided on
January 25, 2021.

You asked the Plan to pay for the non-transport ambulance service. You say that the service should be covered.
The Plan denied your request. The Plan says Medicare only covers ground ambulance transportation when
needed to be transported to a hospital, critical access hospital, or skilled nursing facility for medically
necessary services.

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 January 25, 2021. 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 non-transport ambulance service (A0429), provided on January 25, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a continuous positive airway pressure (CPAP) machine.

You asked the Plan to pre-approve the CPAP machine. You say that your CPAP machine has been recalled and
is unsafe for continued use. The Plan denied your request. The Plan says that the enrollee's current CPAP is less
than 5 years old and is safe for use. The Plan says that a replacement CPAP is not medically necessary at this
time, per their policy.

The Plan must follow Medicare rules. Medicare rules say that the Plan is responsible for maintaining continuity
of care for its enrollee by ensuring uninterrupted access to the medically necessary covered DME item,
including when items need to be repaired or replaced. If necessary, the plan must purchase or rent a
replacement item for the beneficiary to use.

We looked at the file and Medicare rules. The case file shows that the enrollee's existing CPAP machine was
recalled by the manufacturer. The records show that the enrollee's provider has determined that continued used
of this recalled machine is not safe. The Plan has not demonstrated that they have ensured access to a usable
CPAP for the enrollee. Based on this information, we decided that Medicare rules for coverage of the CPAP
machine have been met. Therefore, we decided that the Plan has to pre-approve a continuous positive airway
pressure (CPAP) machine.

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 pre-approve genicular nerve radiofrequency ablation for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is considered experimental and investigational.

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 the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is an experimental/investigational procedure which is the subject of ongoing clinical trials. Therefore, the request is deemed not medically reasonable or 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a filling (D2394) provided on February 23, 2021.

You asked the Plan to pay for a filling. You say that the provider told you this service would be covered. The Plan denied your request. The Plan says the service at issue 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. Therefore, we decided that the Plan does not have to pay for a filling (D2394) provided on February 23, 2021.