Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on June 26, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were
billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. The rules also say that the information submitted
by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and
confirm that Medicare coverage criteria have been met.
We find that diagnosis codes M17.11 and M17.12 are not supported in the medical record. Specifically, there is
a more appropriate diagnosis code to be used in this instant, M17.0. As the enrollee has the same diagnosis for
both knees, it is inappropriate to bill the unilateral diagnosis code for each knee, rather than the single bilateral
diagnosis code. Based on this information, we decided that Medicare rules for coverage of the services have not
been met. Therefore, we decided that the Plan does not have to pay for the services provided on June 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for endodontic therapy (D3330) received on March 11, 2020.
You asked the Plan to pay for the therapy. You say that this should be reprocessed and paid for. The Plan
denied your request. The Plan says the benefit maximum 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. The Plan covers dental
services with up to a $1,000 yearly maximum.
The plan's annual maximum for dental services has already been reached. The plan cannot pay any further for
these services. Based on this information, we decided that the Plan's rules for coverage of the therapy have not
been met. Therefore, we decided that the Plan does not have to pay for endodontic therapy (D3330) received on
March 11, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for SNF care provided from April 1, 2020, to May 23, 2020.
You asked the Plan to waive the copayment for SNF care. The Plan denied your request. You say that this facility charges $5,000 a month, and do not understand why the self-pay bills are so high. The Plan says a lesser total copayment amount was applied for the inpatient SNF services. The Plan also says that the claims are not being reprocessed to apply the actual copayment amount, and the Plan will not waive the remaining copayment amounts.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay $0 copayment per day for days 1-20 and a $178 copayment per day for days 21-100 for each SNF stay for Skilled nursing facility (SNF) care. This SNF stay lasted 53 days, resulting in a total copayment amount of $5,874. The Plan applied a lesser total copayment for these SNF days, resulting in a total copayment amount of $3,736. The enrollee has been asked to pay $0 copayment per day for days 1-20 and a $178 copayment per day for days 21-100 for each SNF stay for SNF care. SNF care falls within the Skilled nursing facility (SNF) care benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for SNF care provided from April 1, 2020, to May 23, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the emergency room services provided on July
24, 2020.
You asked the Plan to waive the copay for the services provided. You say that you were brought to the hospital
against your will due to a possible stroke. The Plan denied your request. The Plan says the claim was processed
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 a $90
copay for each emergency room visit.
You have been asked to pay a $90 copay for the services provided. The services fall 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 copay for the emergency room services
provided on July 24, 2020.
Your complaint that you refused services that were forced on you 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the EKGs provided from May 28, 2020, to July 9, 2020.
You asked the Plan to waive the copayments for the EKGs. You say that the EKGs are maintenance procedures that have the copayment waived. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25 copayment for in-network Medicare-covered non-radiological diagnostic services. You have been asked to pay a $67.04 copayment for the EKGs. The EKGs 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 copayments for the EKGs provided from May 28, 2020, to July 9, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve outpatient therapy. You say that you are not satisfied with the in-network provider options and this provider would be more beneficial to the enrollee. The Plan denied your request. The Plan says the denial of authorization for these services is correct, because this provider is out-of-network with the Plan and the enrollee can be treated by an in-network 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the breast ultrasound provided on August 25,
2020.
You asked the Plan to waive the copay for the services provided. The Plan denied your request. The Plan says
the copay was correctly 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 $160
copay for each Medicare-covered radiological diagnostic service, such as ultrasounds.
You have been asked to pay $85.38 for the ultrasound. Because the amount is less than the $160 copay, you
were charged the lesser amount. The services fall within the outpatient diagnostic tests benefit category. The
Plan's cost share waivers due to Covid-19 do not include diagnostic tests. 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 dec
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed.
You asked the Plan to pre-approve the bed. You say that this is medically necessary. The Plan denied your
request. The Plan says the coverage criteria requires documentation of a need for frequent and immediate
changes in body position.
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered
medically necessary when the patient:
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or
2. Requires attachments which can only be attached to a hospital bed; AND
3. Requires frequent changes in body position and/or has an immediate need for a change in body position.
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 bed. Our reviewer says that the
requested bed is not medically reasonable or necessary. Our physician reviewer found the documentation does
not support a need for an immediate or frequent change in body position or special attachments that cannot be
fixed on an ordinary bed. The request for a semi-electric hospital bed is not medically necessary for you.
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 bed have not been met. Therefore, we decided that the Plan does not have to
pre-approve a semi-electric hospital bed.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided by an out of network (OON) provider.

You asked the Plan to pay for laboratory testing. You say that your services were medically necessary.The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and the ordering provider is also out-of-network with the Plan.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay for the medical services provided by an out of network (OON) provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided to the enrollee on August 25, 2020.
You asked the Plan to pay for the visit. You say that the treatment provided while the enrollee was inpatient
was medically necessary. The Plan denied your request. The Plan says permission was not asked for prior to
services being performed.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for an office visit provided to the enrollee on August
25, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation services
(A0425) provided on August 27, 2020.
You asked the Plan to waive the copayment for the ambulance transportation services provided on August 27,
2020. You say that you should not be responsible for the copay for the ambulance transportation services
because they were provided without your consent. First, your employer called an ambulance to take you to a
hospital, then you were transferred to another hospital to have an emergency medical procedure. The Plan
denied your request. The Plan says the correct copay amount has been applied for these services.
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 ambulance transportation services.
You have been asked to pay a $225 copayment for ambulance transportation 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 services provided on August 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on June 24, 2020, by an out-of-network provider.You asked the Plan to pay forthe medical services. You say that you are appealing for reconsideration of the denied charges.The Plan denied your request. The Plan says you do not have out-of-network benefits.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe medical services provided on June 24, 2020, by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a recliner lift chair.
You asked the Plan to pre-approve the chair. You say that this is medically necessary. The Plan denied your
request. The Plan says this is considered furniture and is not used to care for a medical problem.
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions
listed above are met.
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 chair. Our reviewer says that the
requested chair is not medically reasonable or necessary. Our physician reviewer found the documentation does
not reveal objective evidence that you have severe arthritis of the hip. The documentation does not reveal that
you have a neuromuscular disease. The documentation does not indicate a seat lift mechanism in included in a
treating medical practitioner's treatment plan. The documentation does not support that a seat lift is likely to
effect improvement in your condition or arrest or retard deterioration in your condition. The records do not
indicate that you are is completely incapable of standing from a chair in the home on an objective physical
exam. The records indicate that you can ambulate on an objective gait evaluation.
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 chair have not been met. Therefore, we decided that the Plan does not have
to pre-approve a recliner lift chair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pay fordental services (D0220 and D0140) provided to the enrollee on August 18, 2020.You asked the Planto pay forthe services. You say that you were advised this would be covered.The Plandenied your request. The Plansaysthis is not a covered benefit.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. Forthat 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 Plandoes not haveto pay fordental services (D0220 and D0140) provided to the enrollee on August 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two crowns provided on February 5, 2020 by an OON provider.
You asked the Plan to pay for the crowns. You say that you would like to appeal these services. The Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that there is no coverage when services are rendered by an OON provider.
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 two crowns provided on February 5, 2020 by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient acute services received from
January 23 through January 27, 2020.
You asked the Plan to waive the copayment for inpatient acute services. You say that you cannot afford this bill
because you live on a fixed income. The Plan denied your request. The Plan says your inpatient stay was for
four days.
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 $300
copayment per day for days one through six for inpatient hospital care.
You have been asked to pay a $1,200 copayment amount in total (or a $300 copayment per day for four days)
for inpatient acute services. Inpatient acute services falls within the inpatient hospital 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 inpatient acute services received from January 23 through
January 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair and accessories for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary.The Plan denied your request. The Plansaysthe services in question are not covered under your contract under any normal circumstances.

The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 

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 services. Our reviewer says that the requested wheelchair and accessories are not medically reasonable or necessary. Our physician reviewer found the documentation states the enrollee's mobility deficit is unable to be helped by a manual wheelchair due to wrist pain, but the documentation does not reveal clear documentation of the wrist or indication that the enrollee could not use a manual wheelchair with a modification for improved propulsion. The documentation does not indicate that a group two multiple power option wheelchair is medically necessary. The documentation does not indicate on the treating medical practitioner progress notes that the enrollee is at high risk for development of a pressure ulcer, utilizes intermittent catheterization for bladder management or requires a power seating system to manage increased tone or spasticity. The enrollee does not use a ventilator. As the requested K0843 wheelchair is not appropriate the additional accompanying requests for a wheelchair back cushion (E2612), positioning accessory (E0955), specialized arm height, or  swing-away, retractable, or removable hardware (E1028) accessories are also not medically necessary.

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 services have not been met.Therefore, we decided that the Plan does not have to pre-approve a power wheelchair and accessories for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the pin retention (D2951) provided on July 28, 2020.
You asked the Plan to pay for the pin retention. You say that a pin had to be inserted to keep the new filling in.
The Plan denied your request. The Plan says this service is not 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 pin
retention (D2951) provided on July 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit received on August 25, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says you are responsible for this entire charge.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary
for items or services provided directly by a physician or practitioner who has opted out of the program except
in cases involving emergencies or urgently needed care.
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for an office
visit received on August 25, 2020.