Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from July 3, 2019 through July 9 2019.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file shows that you were admitted on July 3, 2019 and discharged on July 9, 2019. You were asked to pay a $150 copayment per day from July 3, 2019 through July 8, 2019, days 1-6 of your inpatient hospital care. You were discharged on July 9, 2019 and there was no copayment charge for the day of discharge. Per your contract there is a $150 copayment per day required for days 1-8. 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 inpatient hospital care from July 3, 2019 through July 9 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the specialist office visits or the breathing tests provided on October 1, 2019 and November 5, 2019.
You asked the Plan to waive the deductible the specialist office visits and the breathing tests. You say that you were told this provider was in-network and that you would have a $35 copayment and no one told you about the deductible. 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 $500 deductible that applies towards out-of-network specialist office visits and out-of-network diagnostic procedures and tests. The specialist office visits you asked the Plan to waive the deductible falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The breathing tests you asked the Plan to waive the deductible falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $500 deductible that applies towards out-of-network specialist office visits and out-of-network diagnostic procedures and tests. The record shows the provider is out-of-network.
This cost sharing is a contractual obligation that had not been met at the time the specialist office visits and the breathing tests were received on October 1, 2019 to November 5, 2019. Therefore, we decided that the Plan does not have to waive the deductible for the specialist office visits and breathing tests provided on October 1, 2019 and November 5, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for CPT code 95861 provided on July 6, 2019.
You asked the Plan to pay for CPT code 95861. You say that the medical records support the billing of CPT code 95861. The Plan denied your request. The Plan says that the medical records do not support the billing of CPT code 95861.
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 95861 is Needle electromyography; 2 extremities with or without related paraspinal areas. 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 CPT code 95861. Our reviewer says that the medical records support the billing of CPT code 95861. Our physician reviewer found in this case the records provided for review indicated that spontaneous EMGs were recorded during the course of the procedure. The technologists' notes listed the equipment used and the modalities monitored. The physician's final report also demonstrated that EMG was monitored during the course of the procedure. This documentation would satisfy the use of the CPT code in question. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CPT code 95861 have been met. Therefore, we decided that the Plan has to pay for CPT code 95861 provided on July 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora trigger point injection provided on October 22, 2019 by an out of network (OON) provider.You asked the Plan to pay fora trigger point injection. You say that these services were medically necessary.The Plan denied your request. The Plan says no prior authorization was obtained.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 fora trigger point injection provided on October 22, 2019 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 cone beam computed tomography (CT) scan of the maxillofacial area (70486) provided on November 20, 2019.
You asked the Plan to pay for the cone beam CT scan. You say that you were advised you needed to pay for the service up front and your plan would reimburse you. You say that you asked the office staff to bill your dental insurance for the service to which she said she was not going to do that. You also say that you went back 10 minutes later to request the service also be billed to your medical plan. The Plan denied your request. The Plan says services related to temporomandibular joint (TMJ) syndrome are not covered.
The Plan must follow Medicare rules. The rules say that Medicare covers treatment for TMJ syndrome only when the condition or symptom is medical in nature. The treatment must also be medically reasonable and necessary. 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 cone beam CT scan. Our reviewer says that the service is not medically necessary. Our physician reviewer found that the documentation supports the billed diagnosis of left TMJ disc displacement without reduction. The documentation supports that the cone beam CT scan is primarily focused on a medical condition. The limitation in jaw mobility is akin to any joint that is restricted in mobility and does not involve any structures that support the teeth. The reviewer found that more advanced scans are typically reserved for when symptoms are not resolving after initial therapies. Cone beam CT scans have not been shown to be useful in diagnosing cases of internal derangement. Therefore, the reviewer found that a cone beam CT scan is not medically reasonable. 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 cone beam CT scan have not been met. Therefore, we decided that the Plan does not have to pay for the cone beam computed tomography (CT) scan of the maxillofacial area (70486) provided on November 20, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye exam provided on January 28, 2019.
You asked the Plan to waive the copayment for the eye exam. You say that this was a routine eye exam and should have no cost-share for you. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received a medical vision exam with refraction on January 28, 2019. Your claim is processing in accordance with the medical records. Therefore, you are asked to pay a $35 copayment for the Medicare-covered eye exam to diagnose and treat diseases and conditions of the eyes. 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 eye exam provided on January 28, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for pathology services provided on September 19, 2019 by an out of network (OON) provider.You asked the Plan to pay for pathology services. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says no prior authorization was obtained for these services.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 pathology services provided on September 19, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the portable oxygen system provided to the enrollee October 9, 2019.You asked the Plan to waive the coinsurance forthe portable oxygen system. The Plan denied your request. The Plan says that the enrollee pays a %10 coinsurance for Medicare-covered durable medical equipment and related supplies.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 a 10% coinsurance for Medicare-covered durable medical equipment and related supplies. The enrollee has been asked to pay a 10% coinsurance for the portable oxygen system. The portable oxygen system falls within the Medicare-covered durable medical equipment and related 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 forthe portable oxygen system provided to the enrollee October 9, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on September 16,
2019. You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says
non-emergent, non-urgent services with out-of-network 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 requested provider in this case is not a network provider with the Plan. 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 subsequent nursing facility care provided on September 16, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea standard walker.You asked the Plan to pre-approvea standard walker. You say that the four wheeled walker is too heavy to get in your car.The Plan denied your request. The Plan says that your current equipment meets your mobility needs for home use.The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary.The file shows that you have a four wheeled walker. Afour wheeled walker serves the same purpose as a standard walker.Therefore, we decided that the Plan does not have to pre-approvea standard walker.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean electronic connection between wheelchair controller and two or more power seating system motors (CPT E2311).You asked the Plan to pre-approvethe electronic connection between wheelchair controller and two or more power seating system motors. You say that the equipment in dispute is appropriate for the enrollee, who is in distress.The Plan denied your request. The Plan says there is not a medical need to control the power options through a joystick.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 electronicconnection between wheelchair controller and two or more power seating system motors. Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation notes that the plan approved group 3 power wheelchair with power tilt power recline and power elevating leg rests. The enrollee does not require the E2311 controller as the enrollee's right upper limb strength and function is sufficient for the enrollee to operate the controls with their own included power options already included in the allowance for these options. There is not a need to control the power options with a joystick, sip and puff or other non-proportional device, or to operate 3 or more actuators through the drive control. The enrollee does not require a separate display, an attendant control and other electronic devices.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 electronic connection between wheelchair controller and two or more power seating system motors have not been met.Therefore, we decided that the Plan does not have to pre-approvean electronic connection between wheelchair controller and twoor more power seating system motors (CPT E2311)
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the DME provided on December 19, 2019.
You asked the Plan to waive the coinsurance for the DME. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
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 EOC clearly states, you pay 20% coinsurance for Medicare covered DME. You are responsible for the coinsurance.The provider gave you a discount on the coinsurance and charged you $15. You paid the $15 coinsurance on December 19, 2019. The Plan will not reimburse the coinsurance to you. 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 DME provided on December 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and partial lower denture (D5214).
You asked the Plan to pre-approve a complete upper denture and partial lower denture. You say that the items are necessary since you have been unable to get the dental work that was started completed and it is effecting your ability to eat properly. The Plan denied your request. The Plan says the benefit has been exhausted.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers one complete upper denture and one partial lower denture once per 60 months. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a complete upper denture and partial lower denture have not been met. Specifically, the records show that you received a partial lower denture on April 14, 2015 and a complete upper denture on October 22, 2019. This means that you are not eligible for health plan coverage of a complete upper denture and a partial lower denture at this time. Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110) and partial lower denture (D5214).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve implantable wireless pulmonary artery pressure sensor with delivery catheter, including all system components
You asked the Plan to pre-approve implantable wireless pulmonary artery pressure sensor with delivery catheter, including all system components. You say that the records provided should support the necessity of the services in dispute. The Plan denied your request. The Plan says the requested item is not medically necessary for appropriate cardiac care and management of this enrollee's health condition and this device is considered as experimental.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. We looked the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of implantable wireless pulmonary artery pressure sensor with delivery catheter, including all system components have not been met. Therefore, we decided that the Plan does not have to pre-approve implantable wireless pulmonary artery pressure sensor with delivery catheter, including all system components
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided on October 14, 2019 by an out of network (OON) provider.
You asked the Plan to pay for skilled nursing services. You say that these services were medically necessary. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained.
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 skilled nursing services provided on October 14, 2019 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 additional intraoral x-ray, pulp vitality tests and root
canal provided on September 17, 2019.
You asked the Plan to pay for the intraoral x-ray, pulp vitality tests and root canal. You say that this should
have been a free second opinion. You say that you should be refunded. The Plan denied your request. The Plan
says these are not covered 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.
Though the Plan offers a dental benefit in excess of Medicare coverage, the Plan also has a maximum benefit
of one intraoral x-ray per year. The pulp vitality tests and root canal are not covered under the supplemental
benefits. Therefore, we decided that the Plan does not have to pay for the additional intraoral x-ray, pulp
vitality tests and root canal provided on September 17, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve laminectomy for the enrollee.
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your request. The Plan says the requested procedure is supported when there was treatment that didn't help.
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 surgery. Our reviewer says that the requested surgery is not considered medically reasonable and necessary in this case. Our physician reviewer found the MRI does not show severe spinal stenosis. There is no correlation between the imaging and the exam. Criteria for the surgery is not met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve laminectomy for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve massage therapy for the enrollee.You asked the Plan to pre-approve the therapy. You say that this is medically necessary.The Plan denied your request. The Plan says this is not a covered benefit.The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist.Therefore, we decided that the Plan does not have to pre-approve massage therapy for the enrollee