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

We decided that the Plan does not have to issue reimbursement for the wig (A9282) and the sales tax (S9999) purchased on August 29, 2020.
You asked the Plan to issue reimbursement. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says this item is not a covered benefit under your contractual policy or by Medicare.
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are ordered by a physician. The Plan follows these same rules. In this case, although the wig may be appropriate for you, it does not meet the definition of the above benefit categories. It is not considered DME because it does not directly treat a medical condition.
It does not meet the Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would provide coverage for a wig. Therefore, we decided that the Plan does not have to issue reimbursement for the wig (A9282) and the sales tax (S9999) purchased on August 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the frames, bifocal lens, photochromatic tint, and U-V lens received January 20, 2021.
You asked the Plan to pay for the vision care items. You say that the requested items are necessary. The Plan denied your request. The Plan says you have a $150 allowance for supplemental eyewear every year, and you are responsible for all costs over and above the allowance amount.
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 covers these services up to the $150 benefit allowance. We looked at the file and the Plan's rules. You exhausted your $150 benefit allowance in this claim. The Plan contract states you are responsible for any amount over the benefit allowance. Based on this information, we decided that the Plan's rules for coverage of the vision care items have not been met. Therefore, we decided that the Plan does not have to pay for the frames, bifocal lens, photochromatic tint, and U-V lens received January 20, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the intravitreal injection of a pharmacologic agent (67028) and the Bevacizumab injections (C9257 x 2) provided on October 7, 2020.
You asked the Plan to waive the cost share. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the cost share has been applied correctly to the services provided.
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 20% coinsurance for each Medicare-covered Part B drug. Additionally for the administration of that drug, you will pay the cost sharing that applies to primary care provider services, specialist services, or outpatient hospital services depending on where you received the drug administration or infusion services. You pay a $245 copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges. You have been asked to pay $250.35 which includes a $245 copayment for the Medicare-covered surgery provided to you at an outpatient hospital. This amount also includes $2.06 ($10.29 x 20% coinsurance) and $3.29 ($16.46 x 20% coinsurance) for the Medicare Part B drugs provided. 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 share for the intravitreal injection of a pharmacologic agent (67028) and the Bevacizumab injections (C9257 x 2) provided on October 7, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid provided on August 17, 2020.
You asked the Plan to pay for the infectious agent detection by nucleic acid. You say that you have no knowledge of enrollee 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 infectious agent detection by nucleic acid provided on August 17, 2020.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pay for the ultrasonic guidance rendered on July 24, 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 that procedure code 76937 is not supported.
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 76937 is ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent realtime ultrasound visualization of vascular needle entry, with permanent recording and reporting (List separately in addition to code for primary procedure). We find that CPT code 76937 is supported in the medical record. Specifically, the records state that a triple lumen catheter was placed in the right femoral vein with direct ultrasound guidance. Based on this information, we decided that Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pay for the ultrasonic guidance rendered on July 24, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from November 30, 2020, through December 7, 2020.

You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says that an inpatient admission is not medically necessary.

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 that the record shows that at the time of the inpatient admission, the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED 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 from November 30, 2020, through December 7, 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy provided by a participating provider on November 9, 2020, to December 14, 2020.
You asked the Plan to waive the copayment for physical therapy. You say that you do not agree with these charges. The Plan denied your request. The Plan says the correct copayment has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 copayment for outpatient rehabilitation services/in-network. You have been asked to pay a $35 copayment for each physical therapy. The total amount you are being asked to pay is $245 ($35 x 7 sessions = $245). The correct copayment has been applied to the services that were provided. Physical therapy falls within the outpatient rehabilitation services/in-network 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 physical therapy provided by a participating provider on November 9, 2020, to December 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for disposable contact lenses (S0500) purchased on January 19, 2021. You asked the Plan to pay for disposable contact lenses. You say that ordering contacts online was the only way you could find that particular brand of contacts. The Plan denied your request. The Plan says the maximum benefit has been exceeded for the calendar year.
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 covers these services up to a $200 benefit toward the purchase and fitting of eyeglasses and pair of lenses or contact lenses to be used once per calendar year. The benefit can only be used one time. Any remaining benefit dollars do not roll over to a future purchase. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of disposable contact lenses have not been met. Specifically, the record shows that you had exhausted your eyewear benefit maximum of $200 on January 6, 2021. Therefore, we decided that the Plan does not have to pay for disposable contact lenses (S0500) purchased on January 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite (D2392) provided on January 14, 2021.

You asked the Plan to pay for the resin-based composite. You say that you have a dental rider, and this service is covered. The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan. The Plan also says that you were not enrolled in the rider at the time of this service.

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 record shows that you have never been enrolled in an optional dental rider. Therefore, we decided that the Plan does not have to pay for the resin-based composite (D2392) provided on January 14, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapy services rendered on October 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 services are not covered.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.
We looked at the file and Medicare rules. The file shows that multiple therapy services were billed by the
provider. No medical records were included to support the medical necessity of the services. 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 pay for the therapy services rendered on October 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a grab bar provided on October 14, 2020.
You asked the Plan to pay for a grab bar. You say that your wife is having difficulty walking and has balancing
issues. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that grab bars are not covered because
they are not primarily medical in nature.
While a grab bar 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 pay for a grab bar provided on October 14, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation.
You asked the Plan to pre-approve additional routine transportation. You say that the additional transportation is necessary. The Plan denied your request. The Plan says the benefit has been exhausted. Therefore, coverage criteria have not been met.
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 60 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 additional routine transportation.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from December 21, 2020, through December 24, 2020.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the services provided.
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 $195 copayment each day for days 1 to 8 and a $0 copayment for additional Medicare-covered days for in-network Medicare-covered hospital care.
You have been asked to pay $585 ($195 copayment x 3 days) for the inpatient hospital care provided. For inpatient hospital care, cost-sharing applies each time you are admitted to the hospital. 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 inpatient hospital care provided from December 21, 2020, through December 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the gingival irrigation (D4921) provided on February 3, 2021.
You asked the Plan to pay for gingival irrigation. You say that you did not have this service provided on the date in question; you say you only had a deep cleaning and an extraction. The Plan denied your request. The Plan says they contacted the providers office and confirmed that this was one of the deep cleaning services provided. This service is not listed as a covered benefit under your dental plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the gingival irrigation (D4921) provided on February 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the limited oral evaluation (D0140), the panoramic x-ray (D0330), the extraction (D7140), and the collection and application of autologous blood concentrate product (D7921) provided on January 19, 2021.

You asked the Plan to pay more for the dental services. You say that the plan should pay more for these services. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that when you use an out of network provider, you might be billed for any amount greater than what the plan pays. The Plan also says that collection and application of autologous blood concentrate product is not listed as a covered service.

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 the limited oral evaluation, panoramic x-ray, and the extraction are listed as covered, out of network providers may bill you for any amount greater than what the plan pays.

Additionally, collection and application of autologous blood concentrate product is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay more for the limited oral evaluation (D0140), the panoramic x-ray (D0330), the extraction (D7140), and the collection and application of autologous blood concentrate product (D7921) provided on January 19, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge day management provided on March 9, 2020.
You asked the Plan to pay for the hospital discharge day management. You say that you would like this service to be reconsidered for payment. 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 hospital discharge day management provided on March 9, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the re-cement or re-bond of the fixed partial denture (D6930) provided on January 19, 2021.
You asked the Plan to pay for the dental service. You say that this is a covered service. You also say that the receptionist checked before your appointment and confirmed that this service was covered. The Plan denied your request. The Plan says that acid etching, cement bases, cavity lines, and bases or temporary fillings are an exclusion.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. the decision made for this service was based on the Dental Certificate for preventive dental services only. The record shows that the enrollee was enrolled in the supplemental dental rider on the date of service in this case. Without the correct Certificate of Coverage, we cannot confirm that the service is not covered. Additionally, the exclusion used to deny this service is also listed in a section which states "Medicare Advantage Participating Dentists may not charge Members for these services or supplies." Therefore, we decided that the Plan has to pay for the re-cement or re-bond of the fixed partial denture (D6930) provided on January 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered to you from February 21, 2020 to February 22, 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 provider type is not covered.
The Plan must follow Medicare rules. The rules say that Medicare pays for services only when they are furnished by a provider or supplier enrolled in the Medicare program. The file shows that the provider was not Medicare-certified during the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the services rendered to you from February 21, 2020 to February 22, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says a discharge to a lower level of care would not be appropriate if the enrollee has ongoing acute care needs.
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. Our physician reviewer found there is no documentation provided necessitating admission to a LTACH. 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. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan.
The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 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-approve admission to a long term acute care hospital (LTACH) for the enrollee.