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

We decided that the Plan does not have to waive the deductible for the specialist office visit provided on January 7, 2020.
You asked the Plan to waive the deductible for the specialist office visit. You say that you should only be paying a $50 copayment for a specialist office 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. Your contract with the Plan says that there is a $500 combined deductible that applies towards in-network specialist office visits. The specialist office visit you asked the Plan to waive the deductible for falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 combined deductible that applies to an in-network specialist office visit. This cost sharing is a contractual obligation that had not been met at the time the specialist office visit was received on January 7, 2020. Therefore, we decided that the Plan does not have to waive the deductible for the specialist office visit provided on January 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CPM exercise device for use other than knee (E0936).
You asked the Plan to pre-approve the CPM device. You say that you have a shoulder problem. The Plan denied your request. The Plan says the Medicare rules have not been met.
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 the CPM device have not been met. Your provider asked for a stretching machine because you have a shoulder problem. Medicare criteria for a constant stretching machine do not cover this. Medicare only covers the device after certain types of knee surgery. Neither Medicare nor your health plan covers this. Therefore, we decided that the Plan does not have to pre-approve CPM exercise device for use other than knee (E0936).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids purchased on November 26, 2019.
You asked the Plan to pay for the hearing aids. You say that when you called the plan to determine if you had coverage for hearing aids you were told yes. You were never informed there was a vendor network. To your knowledge there is no network vendor in your area. The Plan denied your request. The Plan says hearing aids ordered through providers other than the network vendor 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 purchased from a network vendor. 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 the hearing aids purchased on November 26, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the limited oral evaluation (D0140), the cone beam CT capture and interpretation with limited field of view (D0364) provided on August 12, 2019, and the Leukocyte-platlet rich fibrin (D9999 x 2), the bone replacement graft for ridge preservation (D7953), the surgical extraction (D7210), core build up (D2950), and the porcelain crown (D2740), provided on August 26, 2019. 
You asked the Plan to reimburse you for the dental services. You say that you were advised there was a mass on your right sinus cavity. You say that you had surgery to remove it and still had inflammation. You say that you saw an endodontist who advised you would need to have a previous root canal repaired to treat the inflammation. You say that you elected to have the tooth pulled. You also say that the services you received should be reviewed under your medical plan. The Plan denied your request. The Plan says the services you received are dental in nature. The Plan also says that the maximum amount of coverage for non-Medicare covered dental services has already been reimbursed.
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 maximum allowance of $900 has already been reimbursed. The record shows that the Plan reimbursed you $663 for date of service March 12, 2019 and $227 for date of service March 12, 2019. Additionally, the services you are asking the Plan to pay 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 for the limited oral evaluation (D0140), the cone beam CT capture and interpretation with limited field of view (D0364) provided on August 12, 2019, and the Leukocyte-platlet rich fibrin (D9999 x 2), the bone replacement graft for ridge preservation (D7953), the surgical extraction (D7210), core build up (D2950), and the porcelain crown (D2740), provided on August 26, 2019.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay an additional amount ($34) for the bitewing x-rays (D0274), the periodic
oral exam (D0120), and the dental cleaning (D1110) provided on August 12, 2019.
You asked the Plan to pay an additional amount ($34) for these services. You say that you are requesting a
reconsideration of the Plan's denial as you feel the claim was not processed correctly according to your dental
contract. The Plan denied your request. The Plan says that the appropriate cost sharing was applied to the
services rendered.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). When enrollees obtain plan-covered services in a PPO, they may
not be charged or held liable for more than plan-allowed cost-sharing. Providers who are permitted to 'balance
bill' must obtain the amount in excess of the enrollee's cost-sharing (the balance) for services, directly from the
Plan and not from the enrollee. Your contract with the Plan does not say in clear and accurate terms that you
would be liable for balance billing from a non-contracted dentist. The contract explicitly says that as a member
of the Plan, the Plan will not allow providers to balance bill you.
We looked at your contract with the Plan. We did not see where the contract says enrollees must pay more than
the allowable copayment for covered dental services rendered by an out of network provider. This means that
the Plan did not follow Medicare rules for disclosure of cost sharing information. In addition, the Plan is
responsible for the balance billing in this case. Medicare rules forbid enrollees from being charged or held
liable for more than plan-allowed cost-sharing when obtaining Plan covered services in a PPO. Therefore, we
decided that the Plan has to pay an additional $34 (the balance billing amount) for the bitewing x-rays (D0274),
the periodic oral exam (D0120), and the dental cleaning (D1110) rendered by the out of network provider on
August 12, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for the intraoral-periapical radiographic image (D0220), the intraoral-periapical radiographic additional image (D0230), the crown restoration (D6065), the cone beam computed tomography (CT) scan capture and interpretation (D0367), a prefabricated abutment (D6056), an interim abutment (D6051), and the surgical implant (D6010) provided by the out of network provider,from June 4, 2019 to September 4, 2019.
You asked the Plan to issue reimbursement for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were provided by an out of network dentist, without prior authorization.
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. We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met. Specifically, you received dental services from an out of network dental provider. Therefore, we decided that the Plan does not have to pay for the intraoral-periapical radiographic image (D0220), the intraoral-periapical radiographic additional image (D0230), the crown restoration (D6065), the cone beam computed tomography (CT) scan capture and interpretation (D0367), a prefabricated abutment (D6056), an interim abutment (D6051), and the surgical implant (D6010) provided by the out of network provider from June 4, 2019 to September 4, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services (90834) provided on October 22,
2019 to November 5, 2019.
You asked the Plan to pay for the psychotherapy services. You say that the services were medically necessary.
The Plan denied your request. The Plan says the services were not preauthorized or emergent. 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 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 psychotherapy services (90834) provided on
October 22, 2019 to November 5, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the spine surgery procedure rendered on September 23, 2019.
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 claim was not billed correctly.
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 22899 is unlisted spine surgery procedure.
We find that CPT code 22899 is not supported in the medical record. Specifically, the claim was not billed with
the description for the procedure code. 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 spine
surgery procedure rendered on September 23, 2019.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to waive the coinsurance for outpatient rehab services. We decided that the Plan does not have to waive the copayment for hyperbaric oxygen therapyprovided by a participating provider. You asked the Plan to waive the coinsurance for outpatient rehab services. You say that you have never been charged for this before. You say that you think this was incorrectly billed.The Plan says that the correct coinsurance has been applied.We decided that the Planhas to waive the coinsurance foroutpatient rehab services. There is a $40 copayment for hyperbaric oxygen therapy, not a 20% coinsurance. Therefore, we decided that the Plan has to waive the coinsurance for outpatient rehab services. We also decided that the Plandoes not have to waive the copayment for hyperbaric oxygen therapyprovided by a participating provider. he 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 rehab services. The total amount you are being asked to pay is $160 ($40 x 4 = $160). Therefore, we decided that the Plan does not have to waive the copayment for provided by a participating provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care provided to the enrollee from November 29, 2018 through December 4, 2018.You asked the Plan to pay for inpatient hospital care. You say that the claim should be paid.The Plan denied your request. The Plan says no medical records were provided.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 medical records were not received to verify if the services were needed.Therefore, we decided that the Plan does not have to pay for inpatient hospital care provided to the enrollee from November 29, 2018 through December 4, 2018.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the IRF admission and services.You asked the Plan to pre-approve IRF care. You say that an admission to an inpatient rehabilitation facility is medically necessary. The Plan denied your request. The Plan says admission to an IRF does not meet criteria.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 require fifteen hours per week of rehabilitative services and 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 the IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit you had on December 13, 2019.
You asked the Plan to waive the copayment. You say that this was your annual wellness exam. The Plan denied your request. The Plan says you are responsible for the copayment.
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 Medicare-covered visit with a PCP. Review of the file shows that you had a PCP office visit on December 13, 2019. During this visit, you also had your annual wellness exam, which there is a $0 copayment for. You have been asked to pay a $20 copayment for the office visit. The office visit falls within the physician 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 for the office visit you had on December 13, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power wheelchair seat cushion, back cushion, and
electronic connection.
You asked the Plan to pre-approve the power wheelchair seat cushion, back cushion, and electronic connection.
You say that The Plan denied your request. The Plan says you have adequate strength and function to control
the power option using its own switch and you do not meet criteria for the cushions.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We looked at the file and Medicare rules. Documentation shows that you have normal range of motion and 5/5
strength in the left upper limb. Upper limb strength and range of motion are adequate for you to be able to
control the power option using the switch which is included in the allowance of the power option. You do not
have a diagnosis meeting criteria for the cushions. Based on this information, we decided that Medicare rules
for coverage of the power wheelchair seat cushion, back cushion, and electronic connection have not been met.
Therefore, we decided that the Plan does not have to pre-approve power wheelchair seat cushion, back cushion,
and electronic connection.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit (99335) provided on December 14, 2019 by an out of network (OON) provider.
You asked the Plan to pay for an OON domiciliary or rest home visit. You say that the hospital should have obtained authorization. The Plan denied your request. The Plan says these services were not authorized.
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 domiciliary or rest home visit (99335) provided on December 14, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued coverage of a BiPAP device.
You asked the Plan to pre-approve the BiPAP device. You say that the BiPAP is medically necessary. The Plan denied your request. The Plan says rules for coverage are not met.
The Plan follows Medicare rules. Medicare rules say that adherence to therapy is defined as use of PAP =4 hours per night on 70% of nights. 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 BiPAP device. Our reviewer says that coverage criteria has not been met. Our physician reviewer found the record shows usage for at least 4 hrs./night has ranged from 30.1 to 36.7% of nights. This does not meet the requirement of usage on 70% of nights. 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 BiPAP device have not been met. Therefore, we decided that the Plan does not have to pre-approve continued coverage of a BiPAP device.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ambulance transport provided on April 10, 2019 and May 13, 2019.You asked the Plan to waive the copayment forthe ambulance transports. You say that he has to be transferred by ambulance due to his severe medical condition. You say that insurance should pay.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 andcoinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $225 copayment for each one-way Medicare-covered ambulance trip.The enrollee has been asked to pay a $225 copayment for each ambulance transport. The total amountowed is $450 ($225/transport x 2 transports = $450). The ambulance transports fall within the "Ambulance services" 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 copayment forthe ambulance transport provided on April 10, 2019 and May 13, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.You asked the Plan to pre-approve the LTACH services. You say that the enrollee was in a motor vehicle accident which resulted in many injuries. You say that, due to medical complexities, the enrollee needs long-term acute care for vent weaning, wound management, therapy services, and daily physician visits.The Plan denied your request. The Plan says LTACH services are not medically necessary.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 enrollee is currently undergoing treatment at an acute care hospital (ACH) having bounced back and forth between an ACH and an LTACH several times in the last two months. The enrollee initially presented following a motor vehicle collision. She is currently being evaluated for a gastrointestinal bleed. The enrollee has a tracheotomy and is on a ventilator. It is unclear whether ventilator weaning is expected. There is no evidence that the enrollee requires services that are not currently available. There is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs.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-approve long term acute care hospital (LTACH) services.