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

We decided that the Plan does not have to pay for the porcelain/ceramic crown (D2740) and coronal structure buildup (D2950) provided on December 17, 2019.
You asked the Plan to pay for the dental services. You say that this was billed incorrectly under the wrong year and these services should be covered. The Plan denied your request. The Plan says at the time of these services, you had already met your annual maximum of $500 for supplemental dental coverage. After the annual maximum is exhausted, any remaining charges are your responsibility.
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. Documentation shows that your annual maximum had already been met at the time of services. Therefore, we decided that the Plan does not have to pay for the porcelain/ceramic crown (D2740) and coronal structure buildup (D2950) provided on December 17, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on May 30, 2020.
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 rendered are not a covered benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. Cardiovascular disease screening tests are only covered for certain indications. Review of the file shows that the plan uses Local Coverage Determinations, (LCDs) L36129, LCD L36139, and LCD L36523 to support their denial. However, these LCDs are not valid for the provider's billing address state of Texas. Therefore, we are unable to use these LCDs to substantiate our decision. The laboratory services at issue in this appeal were 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 provided on May 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair and grab bars. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs and grab bars are not covered because they are not primarily medical in nature. While a shower chair and grab bars may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMEMS device for the enrollee.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the clinical value and effectiveness of the CardioMEMs device in the setting of Congestive Heart Failure has not been demonstrated in the peer-reviewed literature.
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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The efficacy of the CardioMEMS heart failure system remains uncertain at this time. Further clinical study is needed to determine the efficacy and safety of this device. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for a CardioMEMS device. We looked at this physician's review, the file, and Medicare rules. 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 pre-approve a CardioMEMS device for the enrollee.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on
October 15, 2020.
You asked the Plan to waive the copayment for the emergency room visit. You say that you should not be
charged for the emergency room. You say it was not your fault. 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 a $120
copayment for emergency services at an in-network emergency room.
You have been asked to pay a $120 copayment for the emergency room visit. The emergency room visit 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 copayment for the
emergency room visit provided on October 15, 2020.
Your complaint about your early discharge from the cardiac catheterization procedure is not a valid appeal for
medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does
not permit us to make a decision about these types of complaints.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skin graft procedure provided on September 14, 2020.
You asked the Plan to waive the copayment for the skin graft procedure. You say that you met your maximum-out-of-pocket amount and should not be responsible for the copayment. 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 a $200 copayment for Medicare-covered outpatient surgery in an ambulatory surgical center or hospital outpatient facility. You have been asked to pay a $200 copayment for the skin graft procedure. The skin graft procedure falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows you had not met the maximum out-of-pocket amount.
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 skin graft procedure provided on September 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an ankle-foot orthosis, left (L1971) provided on September 11, 2020.
You asked the Plan to pay for an ankle-foot orthosis. You say that the requested item was legally and accurately prescribed by the physician. The Plan denied your request. The Plan says rules for payment have not been met.
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 an ankle-foot orthosis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the documentation in the case file does not support that the requested ankle-foot orthosis was medically reasonable and necessary for the enrollee in this case, according to the criteria established by Medicare. A physical examination of the ankle and foot would reasonably be required to adequately assess whether the coverage criteria were met. The documentation does not support that the ankle-foot orthosis was medically reasonable and necessary in this case, as there is insufficient documentation of a credible physical examination of the ankles and feet. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an ankle-foot orthosis have not been met. Therefore, we decided that the Plan does not have to pay for an ankle-foot orthosis, left (L1971) provided on September 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the crown (D2740) provided on October 28, 2020.
You asked the Plan to pay more for the dental service. You say that your tooth broke, and you needed a crown. You say that you did not have control over whether your tooth broke. You say that you received a bill for $438.80, which you paid. You say that you thought the rest would be covered by insurance, but you received another bill for the balance. You also say that you were charged the full amount. The Plan denied your request. The Plan says crowns are covered with a 50% coinsurance after the $100 deductible has been met. The Plan says that there is a $1,500 maximum allowance for covered dental services. The Plan also says that the allowance was exhausted while processing this claim.
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 annual allowance of $1,500 has been exhausted.
Date of Service
Plan Paid
2/11/2020
$187
9/30/2020
$636
10/14/2020
$335.20
10/28/2020
$341.80
TOTAL:
$1,500
The Evidence of Coverage clearly states that after your annual dental benefit maximum has been met for the calendar year, you are responsible for the full charges of any additional dental services received during the calendar year. Therefore, we decided that the Plan does not have to pay more for the crown (D2740) provided on October 28, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Polysomnography, sleep staging with four or more additional parameters of sleep, attended by a technologist (95810) provided August 8, 2020 to October 2, 2020.
You asked the Plan to waive the copayment for the sleep study. You say that you had asked multiple times if there was going to be a copay and you were told no, but then received a bill for a $350 copay. The Plan denied your request. The Plan says the plan had processed the claim and the correct copayment has been 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 $95 copayment for all other diagnostic procedures and tests. You have been asked to pay $190 ($95 + $95) copayment for the sleep study. The sleep study falls within the Outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for Polysomnography, sleep staging with four or more additional parameters of sleep, attended by a technologist (95810) provided August 8, 2020 to October 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the consultation (D9310) and unspecified preventive service
(D1999).

You asked the Plan to pay for the dental services. You say that this service should have been coded as an exam.
You say that you called the Plan 3 times prior to your appointment. You say that the plan representative
confirmed that there would be no copay for the services. You also say that the dental office said there would be
no copay. The Plan denied your request. The Plan says consultation and unspecified preventive service are not
listed as covered services.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Additionally, the record shows that in the calls that you made to the
Plan, the services you received on this date of service were not discussed. Therefore, we decided that the Plan
does not have to pay for the consultation (D9310) and unspecified preventive service (D1999).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the four 2D oral/facial photographic images.

You asked the Plan to pay for the 2D oral/facial photographic images. You say that you feel you should not be responsible for the total amount billed. The Plan denied your request. The Plan says this service is 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 four 2D oral/facial photographic images.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical pathology services provided on December 7, 2020.
You asked the Plan to pay for the surgical pathology services. 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 surgical pathology services. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for surgical pathology services provided on
December 7, 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, prior to this hospital stay, the enrollee was fully independent. You say that it would be safer for the enrollee to get more rehabilitation in order to get strong and build his endurance. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met.
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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for COVID-19 pneumonia and sepsis. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a walk-in shower.
You asked the Plan to pre-approve a walk-in shower. You say that you feel the requested item is a medical issue since if you did not have your medical problem you would have no issue getting into the tub. The Plan denied your request. The Plan says rules for pre-approval have not been met because the requested item does not serve a mainly medical purpose.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a walk-in shower.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the periapical x-ray (D0220) provided on
November 20, 2020.
You asked the Plan to reimburse you for the dental service. You say that half of your tooth broke off. You say
that you were in a lot of pain. You say that you bought tooth pain medication, but it did not help. You say that
you went to the dentist to find out what was wrong. You said that you thought the appointment would be
covered because your card says, "Dental Coverage." You also say that you are on a limited income and need
help with this. The Plan denied your request. The Plan says periapical x-ray is not listed as a covered service.
The Plan also says that any services that are not listed 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. The Evidence of Coverage clearly states that any services not listed are
not covered. Therefore, we decided that the Plan does not have to reimburse you for the periapical x-ray
(D0220) provided on November 20, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the CxBladder testing (0012M) provided on September 14,
2020.
You asked the Plan to pay for the CxBladder testing. You say that you would like reconsideration because this
testing is a Medicare covered benefit. The Plan denied your request. The Plan says this service does not meet
Medicare's criteria of medically necessary and reasonable and cannot be approved.
The Plan must follow Medicare rules. Medicare rules say that for the CxBladder assay coded as 0012M, noncoverage
was reaffirmed by Medicare.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the CxBladder testing have not been met. Specifically, per the applicable LCD, this testing is not a
covered benefit. Therefore, we decided that the Plan does not have to pay for the CxBladder testing (0012M)
provided on September 14, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the ground mileage and the non-emergency transports.

You asked the Plan to pay for the transportation services. You say that the services were necessary. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the member's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The rules also say that Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. The enrollee ended Medicare Hospice benefits. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the ground mileage and the non-emergency transports.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided August 24, 2020 to August 27, 2020.
You asked the Plan to pay for acute inpatient hospital care. You say that inpatient care was medically necessary. The Plan denied your request. The Plan says that the enrollee could have been treated at a lower level of 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 supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier Emergency and/or observation care) would span two midnights. 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 been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided August 24, 2020 to August 27, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.