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

We decided that the Plan does not have to pay for the complete denture - maxillary (D5110).

You asked the Plan to pay for the maxillary denture. You say that you have a $500 benefit allowance, so you should receive additional reimbursement from the Plan. The Plan denied your request. The Plan says you had already exhausted a portion of your $500 benefit allowance prior to this date of service, therefore the claim processed correctly.

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 is in excess of those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the complete denture - maxillary (D5110).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee.

You asked the Plan to pay for this claim as billed. You say that these services should be paid by the Plan. The Plan denied your request. The Plan says codes G0156 (140 units), T1021 (320 units) and S9122 (1749 units) are not supported by the records provided. The Plan states the documentation does not include documentation of notes and time spent in the records provided. The Plan states the billed services cannot be verified. The Plan states the provider was contacted and indicated no further records will be submitted to support this claim.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes and when necessary specific records that support the types of codes billed. In this case, the records provided lack the required time reporting element that support the services and units billed. Medicare rules for coverage of this claim as billed have not been met. Therefore, we decided that the Plan does not have to pay for home health services provided to the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit.

You asked the Plan to waive the copayment for a specialist visit. You say that you received results for a sleep study and feel that you should not owe a 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 $35 copayment for specialist services.

You have been asked to pay a $35 copayment for a specialist visit. A specialist 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 a specialist visit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthoses (L1833 and L2397).

You asked the Plan to pay for the knee orthoses. You say that you would like reconsideration because the member received services from this provider. The Plan denied your request. The Plan says there is no evidence that the member received telephonic or in-person services from the ordering provider.

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 pay for the knee orthoses. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested items exceed the member's medical need as the documentation does not reveal a detailed hands on neuromuscular physical examination indicating knee range of motion, strength, degrees of laxity or instability and indications that a properly performed physical examination of laxity of the knees was performed on this member by a physician.

There are no objective imaging studies of the knees confirming a need for the knee orthosis

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 knee orthoses have not been met. Therefore, we decided that the Plan does not have to pay for knee orthoses (L1833 and L2397).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for acupuncture.

You asked the Plan to pay for acupuncture for neck pain that radiated to right shoulder. You say that acupuncture should be covered because it has been beneficial in relieving your pain. The Plan denied your request. The Plan says acupuncture was not a covered benefit under the 2020 Plan contract.

The Plan must follow Medicare rules. The rules say that for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for chronic low back pain only and no more than 20 sessions per year. The 2020 Plan contract did not cover acupuncture under any circumstance.

We looked at the medical records, the case file and Medicare rules. You were treated for neck and shoulder pain; therefore, you did not meet the limited coverage criteria Medicare offers for acupuncture. The Plan offered no coverage for acupuncture supplementally. Therefore, we decided that the Plan does not have to pay for acupuncture.
Appeal type: DME/ Orthotics
Decision: Partially Favorable

We decided that the Plan has to reduce the coinsurance for the walking boot. We decided that the Plan does not have to waive the coinsurance for the walking boot.

You asked the Plan to waive the coinsurance for the walking boot. You say you cannot afford this bill. The Plan says that you have been charged the correct cost-sharing amount.

We decided that the Plan has to reduce the coinsurance for the walking boot.

The record shows that you were charged a 20% coinsurance for the walking boot.

The Plan says that you must pay $41.74 for the walking boot. However, based on the Plan contract you cannot be asked to pay more than $20.87 for the walking boot. Therefore, we decided that the Plan has to reduce the coinsurance for the walking boot from $41.74 to $20.87.

We also decided that the Plan does not have to waive the coinsurance for the walking boot.

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 10% coinsurance for the walking boot. The record shows the allowed amount for the walking boot is $208.70. ($208.70 x 10% = $20.87). Therefore, we decided that the Plan does not have to waive the coinsurance for the walking boot.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the walking boot.

You asked the Plan to waive the coinsurance for the walking boot. You say that you medically need the boot for your ankle and the copayment is too high and should be waived. The Plan denied your request. The Plan says you have been asked to pay 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 10% coinsurance for covered items and related supplies.

You have been asked to pay $32.55 which is 10% of the allowed amount for the walking boot. The allowed amount is $325.53. ($325.53 x 10% = $32.55). The walking boot falls 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 for the walking boot.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says there is no evidence of a four-week trial of a basic lymphedema pump.

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 device. Our reviewer says that the requested device is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no evidence of lymphedema of the chest, trunk, or abdomen on an objective physical examination. You do not have any unique characteristics that would indicate the segmented pump over a standard pump. The documentation does not reveal a failure of a four week trial of a basic pump.

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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care services coded 99233 and 99232.

You asked the Plan to pay for the subsequent hospital care 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 providers must report services correctly. Providers must report services with the appropriate CPT code.

We find that CPT codes 99233 and 99232 are not supported in the medical record. Specifically, these codes ere already billed, processed, and paid under another claim number for these dates of service. This means that these codes are a duplicate. Based on this information, we decided that Medicare rules for coverage of the subsequent hospital care services have not been met. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care services coded 99233 and 99232.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for lab work provided by a participating provider.

You asked the Plan to waive the coinsurance for lab work. You say that you gave the stool sample the same day you went to get your blood drawn. The Plan denied your request. The Plan says the correct copayment has been 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 an $8 copayment for outpatient diagnostic tests/lab tests.

You have been asked to pay an $8 copayment for each lab work. The total amount you are being asked to pay is $16 ($8 x 2 tests = $16). Lab work falls within the outpatient diagnostic tests/lab 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 coinsurance for lab work provided by a participating.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for infusion services.

You asked the Plan to pay for intravenous infusion (96360). You say that the Plan should pay these claims. The Plan denied your request. The Plan says the provider opted out of Medicare.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.

The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for infusion services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee.

You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.

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 services at issue in this appeal. The Plan did not pre-approve the service 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 physician services provided to the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care.

You asked the Plan to pay for acute inpatient hospital care. You say that authorization was not obtained but the inpatient services were medically necessary. The Plan denied your request. The Plan says inpatient services were not needed following the observation care.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.

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 pay for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found based on the medical records provided the record does not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights. Care at the observation level appears to have been appropriate with the option to transition the patient to inpatient status if their condition warranted further hospital level 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 acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit.

You asked the Plan to waive the copayment for a specialist visit. You say that you 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 a $40 copayment for a specialist visit.

You have been asked to pay a $40 copayment for a specialist visit. A specialist 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 a specialist visit.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a tetanus, diphtheria toxoids, and acellular pertussis (TDAP) vaccine and administration.

You asked the Plan to pay for TDAP vaccine. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this immunization is correct, because the TDAP vaccine is not covered by Medicare Part B.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide TDAP vaccine. The Plan follows the same rules.

Records do not show that you have been injured or directly exposed to any illness related to TDAP vaccine. Therefore, we decided that the Plan does not have to pay for a tetanus, diphtheria toxoids, and acellular pertussis (TDAP) vaccine and administration.

Benefits for TDAP vaccine may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services.

You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.

The Plan follows Medicare rules. The rules say that cardiovascular disease screening tests are only covered for certain indications.

The laboratory testing at issue in this appeal was requested solely for screening purposes. While Medicare covers cardiovascular disease screening tests for certain indications, the documentation does not support that the enrollee met criteria for the services rendered. Therefore, we decided that the Plan does not have to pay for the laboratory services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the replacement of broken teeth (D5640).

You asked the Plan to pay for the replacement of broken teeth. You say that you asked the office what the cost of this service would be but were not told. You also say that you were advised this service would be covered by your insurance. The Plan denied your request. The Plan says this service is not a covered benefit under your dental 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. Therefore, we decided that the Plan does not have to pay for the replacement of broken teeth (D5640).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visits and electrical stimulation services provided by a chiropractor.

You asked the Plan to pay for the office visits and electrical stimulation services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received are not a covered benefit.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.

The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the office visits and electrical stimulation services provided by a chiropractor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a supply for a therapeutic continuous glucose monitor (K0553).

You asked the Plan to pay for a supply for a therapeutic continuous glucose monitor. You say that the requested items are needed by the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.

The record does not contain a valid physician order, proof of delivery, or relevant medical records which support medical necessity for the supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for a supply for a therapeutic continuous glucose monitor (K0553).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a Non-powered pressure reducing mattress (E0373), bed safety enclosure (E0316), bed side rails (E0310), bed board (E0315), and over bed table (E0315).

You asked the Plan to pay for a Non-powered pressure reducing mattress, bed safety enclosure, bed side rails, bed board, and over bed table. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the requested mattress does not meet medical necessity criteria and the accessories are not covered.

The Plan must follow Medicare rules. Medicare rules say that for equipment to be covered, it must primarily serve a medical purpose. The rules also say that a group 2 support surface if the enrollee has multiple pressure ulcers. The rules also say that side rails and safety enclosures are covered when they are required by the enrollee's condition and are part of a covered hospital bed.

Pressure Reducing Mattress

In this case, for a pressure reducing mattress to be covered you must have multiple pressure ulcers. The medical records indicate that you do not have multiple pressure ulcers. Therefore, the Medicare rules for coverage have not been met.

Bed Safety Enclosure, Bed Side Rails

Because these items are not a part of a covered hospital bed, coverage cannot be made for the bed safety enclosure and bed side rails.

Bed Board, Over Bed Table

Medicare coverage rules indicate that a bed board and an over bed table are not covered because they are not primarily medical in nature.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Non-powered pressure reducing mattress, bed safety enclosure, bed side rails, bed board, and over bed table have not been met. Therefore, we decided that the Plan does not have to pay for a Non-powered pressure reducing mattress (E0373), bed safety enclosure (E0316), bed side rails (E0310), bed board (E0315), and over bed table (E0315).