Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab tests provided on February 10, 2021.You asked the Plan to waive the copayment for lab tests. You say that the labs were part of your annual wellness exam and 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 $10 copayment for lab tests. You received lab tests on February 10, 2021. Lab tests are not included in annual wellness exams. Therefore, you are responsible to pay the $10 copayment. You have been asked to pay a $10 copayment for lab tests. Lab tests fall within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment for lab tests provided on February 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee brace (L1833, L2397) provided on October 23, 2020.
You asked the Plan to pay for a knee brace. You say that this should be covered. The Plan denied your request. The Plan says the supplier is not enrolled in Medicare.
The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare program. We looked at the file and Medicare rules. The supplier for the items at issue is not enrolled in the Medicare program. Based on this information, we decided that Medicare rules for coverage of a knee brace have not been met. Therefore, we decided that the Plan does not have to pay for a knee brace (L1833, L2397) provided on October 23, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on November 27, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the testing is not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on November 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the partial mandibular overdenture (D5866) provided on August 6, 2020.

You asked the Plan to pay for the partial mandibular overdenture. You say that you believe this service should be covered. 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 partial mandibular overdenture (D5866) provided on August 6, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex Superion device surgery 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 experimental and investigational procedures are not covered by Medicare.

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 vertiflex device is experimental. More research is needed to show safety and efficacy of the device. Our physician reviewer found that the enrollee's condition does not meet criteria for these services.

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 Vertiflex Superion device surgery for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the three crowns (D2740 x3) and core buildup, including any pins when required (D2950) provided on September 28, 2020.You asked the Plan to pay for the crowns and core buildup. You say that you believe these services should be covered.The Plan denied your request. The Plan says these services are not covered 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 three crowns (D2740 x3) and core buildup, including any pins when required (D2950) provided on September 28, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound services represented by current procedural terminology (CPT) code 76770 provided on November 10, 2020.You asked the Plan to pay for CPT code 76770. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the medical records do not support the billing of CPT code 76770.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 76770 is Ultrasound, retroperitoneal (eg, renal, aorta, nodes), real time with image documentation; complete.
We find that CPT code 76770 is not supported in the medical record. Specifically, there is a more appropriate CPT code for the billed service. Based on this information, we decided that Medicare rules for coverage of CPT code 76770 have not been met.Therefore, we decided that the Plan does not have to pay for the ultrasound services represented by current procedural terminology (CPT) code 76770 provided on November 10, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation (A0427, A0425) received December 17, 2020.You asked the Plan to waive the copayment for the ambulance transportation. You say that you normally pay $90 for emergency room services.The Plan denied your request. The Plan says the correct cost share applied to the claim.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for each Medicare-covered one-way trip via ground ambulance. You have been asked to pay a $250 copayment for the ambulance transportation. The service you received is considered a Medicare-covered one-way trip via ground ambulance benefit category. The cost share applied to this claim is for ambulance transportation, not for emergency room services. 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 ambulance transportation (A0427, A0425) received December 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the incomplete endodontic therapy (D3332) provided on February 2, 2021.
You asked the Plan to pay for the incomplete endodontic therapy. You say that you believe this service should be covered. 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 incomplete endodontic therapy (D3332) provided on February 2, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the chlamydia pneumoniae detection, cytomegalovirus detection, enterovirus detection, herpes virus-6 detection, legionella pneumophila detection, mycoplasma pneumoniae detection, respiratory virus detection, staphylococcus aureus detection, infectious agent detection, specimen collection for COVID-19, and COVID-19 detection provided on October 19, 2020
You asked the Plan to pay for the laboratory services. You say that you have no knowledge of the enrollee's coverage prior to the specimen's arrival at the laboratory. The Plan denied your request. The Plan says Original
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the
enrollee's terminal condition.
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 enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for the chlamydia pneumoniae detection, cytomegalovirus
detection, enterovirus detection, herpes virus-6 detection, legionella pneumophila detection, mycoplasma
pneumoniae detection, respiratory virus detection, staphylococcus aureus detection, infectious agent detection,
specimen collection for COVID-19, and COVID-19 detection provided on October 19, 2020
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care provided from October 5, 2020, to October 6, 2020.You asked the Plan to waive the copayment for emergency care. You say that you cannot afford 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 $75 copayment for emergency care. You have been asked to pay a $75 copayment for emergency care. Emergency care 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 emergency care provided from October 5, 2020, to October 6, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve non-emergency transport by taxi (A0100).

You asked the Plan to pre-approve non-emergency transport by taxi. You say that the requested services are a necessity for your care. The Plan denied your request. The Plan says the benefit has been exhausted for the calendar year.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 24 one-way trips per year.

We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve non-emergency transport by taxi (A0100).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for dialysis provided by an out-of-network provider on November 20, 2020.

You asked the Plan to pay for the dialysis. You say that the patient was traveling during this time, so dialysis treatments were received at a different facility. You say that the service was medically necessary, and the claim should be reprocessed for payment. The Plan denied your request. The Plan says that out-of-network providers must obtain authorization before services are rendered.

Medicare rules say that plans can require enrollees to get care from network providers. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis, and pre-approved care. 

Based on this information, we decided that Medicare rules for coverage of the dialysis have been met. The out-of-area dialysis services were received at a Medicare- certified dialysis facility. Therefore, we decided that the Plan has to pay for dialysis provided by an out-of-network provider on November 20, 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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a blood draw (36416) and specimen transfer (99000) provided on February 22, 2021.
You asked the Plan to pay for a blood draw and specimen transfer. You say that you needed these services. The Plan denied your request. The Plan says these services are not separately payable.
The Plan must follow Medicare rules. Medicare rules say that a status code of B indicates that payment for covered services are always bundled into payment for other services not specified. We looked at the file and Medicare rules. The codes for the services at issue have a status code of B. These codes are not separately payable. Based on this information, we decided that Medicare rules for coverage of a blood draw and specimen transfer have not been met. Therefore, we decided that the Plan does not have to pay for a blood draw (36416) and specimen transfer (99000) provided on February 22, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary.The Plan denied your request. The Plan says that the member is receiving appropriate in-patient acute care and does not require transfer to LTACH.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. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services.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-approvelong term acute care hospital (LTACH) services for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex surgery.
You asked the Plan to pre-approve Vertiflex surgery. You say that this request is medically necessary. The Plan
denied your request. The Plan says this request is not medically necessary.
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 Vertiflex surgery. Our reviewer says
that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and
efficacy of the 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 Vertiflex surgery have not been met. Therefore, we decided that the Plan does
not have to pre-approve Vertiflex surgery.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the progressive lens per lens (V2781) received February 1, 2021.

You asked the Plan to pay for the progressive lenses. You say that you have a $150 eyewear allowance that should apply to the progressive lenses. The Plan denied your request. The Plan says your Evidence of Coverage states that progressive lenses are not covered under your supplemental benefit; therefore, you cannot use the $150 allowance.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan's supplemental benefit does not include progressive lenses. 

We looked at the file and the Plan's rules. The Plan contract clearly states that progressive lenses are not covered under your supplemental benefit. Your $150 benefit allowance is only applicable toward lenses which are eligible for coverage. Based on this information, we decided that the Plan's rules for coverage of the progressive lenses have not been met. Therefore, we decided that the Plan does not have to pay for the progressive lens per lens (V2781) received February 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the automatic external defibrillator (K0606) provided on September 21, 2020, by an out of network (OON) provider.
You asked the Plan to pay for the automatic external defibrillator. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered by an OON provider.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the automatic external defibrillator (K0606) provided on September 21, 2020, by an out of network (OON) provider.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips

You asked the Plan to pre-approve the additional trips. You say that you have to go to dialysis three times a
week. The Plan denied your request. The Plan says the request for additional transportation cannot be
approved.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this
case. The Plan covers a maximum of [ENTER PLAN MAXIMUM # OF TRIPS] trips per year.

We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips