Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided on December 23, 2020.

You asked the Plan to pay for a lumbar-sacral orthosis. You say that the requested item is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for a lumbar-sacral orthosis 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 a lumbar-sacral 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 available documentation in the case file does not support that the requested lumbar-sacral orthosis was medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by Medicare. An appropriate history and a physical examination of the back would reasonably be required to adequately assess whether the coverage criteria for a lumbar-sacral orthosis have been met. The documentation does not support that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as the case file does not contain documentation of a physical examination of the back, and there is no indication that the coverage criteria for a lumbar-sacral orthosis were 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 a lumbar-sacral orthosis have not been met. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided on December 23, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient services provided from December 30, 2018, through January 2, 2019 with the reported secondary diagnosis N17.0, acute kidney failure with tubular necrosis.
You asked the Plan to pay for inpatient services provided from December 30, 2018, through January 2, 2019 with the reported secondary diagnosis N17.0, acute kidney failure with tubular necrosis. The Plan denied your request. The Plan says there is insufficient clinical evidence to substantiate the coding of this condition.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services provided with the secondary diagnosis N17.0, acute kidney failure with tubular necrosis. 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 inpatient services provided from December 30, 2018, through January 2, 2019 with the reported secondary diagnosis N17.0, acute kidney
failure with tubular necrosis. Our reviewer says that the documentation does not support that the inpatient care is payable as billed. Our physician reviewer found that the rules state that secondary diagnosis are all conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or the length of stay. Diagnoses that relate to an earlier episode which have no bearing on the current hospital stay are to be excluded. In this case, the record indicates that the enrollee had acute on chronic renal failure that required rehydration. The record does not indicate the presence of acute tubular necrosis. Diagnosis code N17.0 requires the presence of acute tubular necrosis. The elements of the coverage rule are not satisfied. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient services provided from December 30, 2018, through January 2, 2019 with the reported secondary diagnosis N17.0, acute kidney failure with tubular necrosis.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and an intraoral periapical x-ray (D0220) provided on December 23, 2020.
You asked the Plan to pay for the evaluation and x-ray. You say that these were emergency services, and no plan providers were available at the time. The Plan denied your request. The Plan says that routine dental services are not covered by Medicare and can only be covered under the Plan's supplemental dental benefit when provided in-network.
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, items or services provided out-of-network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) and an intraoral periapical x-ray (D0220) provided on December 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee scooter (E0118).
You asked the Plan to pre-approve a knee scooter. You say that this is medically necessary. The Plan denied your request. The Plan says that your request is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that there is insufficient published clinical literature demonstrating safety and effectiveness in the Medicare population to establish the medical necessity for crutch substitutes (E0118). We looked at the file and Medicare rules. The DME MAC, the contractor responsible for coverage of medical equipment in the your state has decided that the knee scooter coded as E0118 is not medically reasonable and necessary. Based on this information, we decided that Medicare rules for coverage of a knee scooter have not been met. Therefore, we decided that the Plan does not have to pre-approve a knee scooter (E0118).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you an additional amount for eyeglasses provided on September 2, 2020.
You asked the Plan to reimburse you an additional amount for the eyeglasses. The Plan denied your request. The Plan says the Plan made a payment of $150. You must pay the difference between the Plan's benefit and the cost of the eyewear.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file and the Plan's rules. The file shows that the Plan paid the correct amount of $150 for the supplemental routine eyewear benefit. Therefore, we decided that the Plan does not have to reimburse you an additional amount for eyeglasses provided on September 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided by an out-of-network provider on November 25, 2020.

You asked the Plan to pay for the office visit. You say that this was denied in error for services that do not require a referral. You say that the claim should be reprocessed.The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not approved in advance.

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 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 office visit provided by an out-of-network provider on November 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial periapical x-ray (D0220), the additional periapical x-ray (D0230), and the panoramic x-ray (D0330) provided on September 8, 2020.
You asked the Plan to pay for the dental services. You say that you had to wait 4 hours to see the dentist for a second opinion. You say that you did not end up seeing the dentist that you preferred. You say that you assumed that you were covered for these services. You also say that you are not going to pay for these services. The Plan denied your request. The Plan says periapical x-rays are not listed as covered services. The Plan also says that panoramic x-ray is not listed as a covered service either.
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 initial periapical x-ray (D0220), the additional periapical x-ray (D0230), and the panoramic x-ray (D0330) provided on September 8, 2020.
Your complaints about having a different provider and the wait time are 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit, ECG and routine venipuncture provided by an out-of-network provider on September 2, 2020.
You asked the Plan to pay for the office visit, ECG and routine venipuncture. You say that the provider is the primary care physician and prior authorization should not be required. The Plan denied your request. The Plan says prior authorization was required but not 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 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 office visit, ECG and routine venipuncture provided by an out-of-network provider on September 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost for the hyaluronan injection and office visit provided October 27, 2020 and the hyaluronan injection provided on November 3, 2020 and November 10, 2020.
You asked the Plan to waive the cost for the hyaluronan injections and office visit. You say that Medicare covers 80% of the cost and your insurance should cover a substantial amount of the remaining 20%. You say that the Plan should stand behind providing supplemental coverage toward the 20% unpaid. The Plan denied your request. The Plan says the cost share applied correctly.
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 20% coinsurance for Medicare Part B covered drugs from an in-network provider and a $25 copayment for provider and professional services at an in-network specialist's office. You have been asked to pay a total of $629.80 for the hyaluronan injections and office visit.
Date of Service
Service
Allowed Amount
Standard Cost
Member Liability
October 27, 2020
Hyaluronan Injection
$1,008
20%
$201.60
October 27, 2020
Office Visit
$76.52
$25
$25
November 3, 2020
Hyaluronan Injection
$1,008
20%
$201.60
November 10, 2020
Hyaluronan Injection
$1,008
20%
$201.60
TOTAL:
$629.80
The hyaluronan injections fall within the "Medicare Part B prescription drugs" benefit category. The office 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 cost for the hyaluronan injection and office visit provided October 27, 2020 and the hyaluronan injection provided on November 3, 2020 and November 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, bitewing x-rays, and prophylaxis provided on December 28, 2020 by an OON provider.
You asked the Plan to pay for the periodic oral evaluation, bitewing x-rays, and prophylaxis. You say that you believe these services should be covered. The Plan denied your request. The Plan says these services were rendered by a non-participating provider. The Plan also says that services need to be provided in-network to be eligible for payment.
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 covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation, bitewing x-rays, and prophylaxis provided on December 28, 2020 by an OON provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency department visit (99283) provided January 2, 2021.
You asked the Plan to waive the copayment for the emergency visit. You say that the EMS should not have taken your mother to the hospital. These are not normal times. You mother should not have to pay any cost share for this abuse and inconvenience. The Plan denied your request. The Plan says this claim was processed, and the correct copayment was 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 $90 copay for each emergency visit. You have been asked to pay $90 copay for the emergency visit. The emergency 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 emergency department visit (99283) provided January 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewings - four radiographic images (D0274) received January 18, 2021.
You asked the Plan to pay for the bitewing x-rays. You say that you did not know that an in-network office could contain out-of-network providers. The Plan denied your request. The Plan says your supplemental benefit does not include bitewing x-rays.
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 Plan does not cover bitewing x-rays, regardless of whether they were performed in-network or out-of-network. Therefore, we decided that the Plan does not have to pay for the bitewings - four radiographic images (D0274) received January 18, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for non-emergent ambulance transportation (A0428, A0425) provided on December 16, 2020 by an out of network provider.
You asked the Plan to pay for the transport. You say that the services were medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained for these services. There were network providers available.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan 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 non-emergent ambulance transportation (A0428, A0425) provided on December 16, 2020 by an out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the re-cement or re-bond a crown and prefabricated post and core in addition to crown provided on November 12, 2020.
You asked the Plan to pay for the re-cement or re-bond a crown and prefabricated post and core. You say that you would like to be reimbursed $300. The Plan denied your request. The Plan says these services 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 Plan has reprocessed your claim and allowed the remaining balance of $143.90 on your debit mastercard to apply toward these services. Therefore, we decided that the Plan does not have to pay for the re-cement or re-bond a crown and prefabricated post and core in addition to crown provided on November 12, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on March 5, 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 claim was billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. 

We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on March 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on October 6, 2020 by an out of network provider.

You asked the Plan to pay for the office visit. You say that the Plan should pay this claim. The Plan denied your request. The Plan says you did not request 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 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 the office visit provided on October 6, 2020 by an out of network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic radiology test and coinsurance for an injection provided by a participating provider on October 27, 2020.
You asked the Plan to waive the copayment for a diagnostic radiology test and coinsurance for an injection. You say that you were not aware that this test would be so costly. The Plan denied your request. The Plan says the correct copayment and coinsurance have 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 a $225 copayment for outpatient diagnostic tests/diagnostic radiology and a 20% coinsurance for Medicare Part B prescription drugs/in-network/provider's office. You have been asked to pay a $225 copayment for a diagnostic radiology test and a 20% coinsurance of the allowed amount for an injection. The total allowed amount is $236.76. The amount you are being asked to pay for the injection is $47.35 ($236.76 x 20% = $47.35). The total amount you are being asked to pay is $272.35 ($225 + 47.52 = $272.35). A diagnostic radiology test and an injection falls within the outpatient diagnostic tests/diagnostic radiology and Medicare Part B prescription drugs/in-network/provider's office 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 diagnostic radiology test and coinsurance for an injection provided by a participating provider on October 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the fillings (D2330) for teeth # 9 and 11, and the filling (D2392) for tooth # 14 provided on December 11, 2020.
You asked the Plan to pay for the dental services. You say that you had a benefit card with $500 that you were going to use for these services. You say that it expired on December 31, 2020. You say that you no longer have money to pay for these services. You also say that you would appreciate any help with this bill. The Plan denied your request. The Plan says 2 fillings are covered per calendar year. The Plan also says that the frequency limit has been exceeded.
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 and fillings are listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for 1 filling that you received on July 10, 2020, and 1 filling that you received on December 11, 2020. Therefore, we decided that the Plan does not have to pay for the fillings (D2330) for teeth # 9 and 11, and the filling (D2392) for tooth # 14 provided on December 11, 2020.