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

We decided that the Plan does not have to waive the copayment for a comprehensive audiometry threshold
evaluation provided on November 20, 2020.
You asked the Plan to waive the copayment for a comprehensive audiometry threshold evaluation. You say that
you were informed the test was free. 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 diagnostic procedures and tests.
You have been asked to pay a $10 copayment for a comprehensive audiometry threshold evaluation. A
comprehensive audiometry threshold evaluation falls within the outpatient diagnostic tests and therapeutic
services and supplies benefit category. This means that you have been asked to pay the correct amount based
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a
comprehensive audiometry threshold evaluation provided on November 20, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forambulance services provided on June 29, 2020.You asked the Plan to waive the copayment forambulance services. You say that you disagree with the charges because the paramedics did not assist the enrollee to the ambulance.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). The enrollee's contract with the Plan clearly says that enrollees must pay a $270 copayment for ambulance services. The enrollee has been asked to pay a $270 copayment for ambulance services. Ambulance services fall within the ambulance services 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 forambulance services provided on June 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the compression stockings identified with code A6530 that
were issued on September 30, 2020.
You asked the Plan to pay for the compression stockings. You say that you were given these stockings before
you left the hospital but were never told of the cost. The Plan denied your request. The Plan says you received
compression stockings in order to assist with your leg swelling. However, these are not covered by Medicare.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are
noncovered because they do not meet the statutory definition of a surgical dressing.
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression
stockings identified with code A6530 that were issued on September 30, 2020.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to waive or reimbursethe cost share for several claims for services provided from August 20, 2019 to October 27, 2019.You asked the Plan to waive or reimbursefunds you believe were overpaid for services provided in 2019. You say that you believe you have overpaid the maximum out of pocket (MOOP) for 2019. The Plan denied your request. The Plan says the claims in question were reviewed. The Plans portion of the services in question have been paidfor each service leaving your contractual copayment expectation for services rendered based on the service 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 in 2019 there was a maximum out of pocket of $4500. The Plan has provided claim and payment information for each service in question. Both the records and the Explanation of Benefits (that you would also have a copy of ) for each service clearly show the balance of the maximum out of pocket at the time of service. You have been asked to pay the correct amount for each service 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 or reimbursethe cost share for several claims for services provided from August 20, 2019 to October 27, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the medical eye exam (92004) and does not
have to pay for the eye refraction services (92015) provided on October 22, 2020.
You asked the Plan to waive the copayment for the medical eye exam and to pay for the eye refraction services.
You say that you would like this claim reprocessed and approved for payment. The Plan denied your request.
The Plan says the copayment has processed correctly for the medical eye exam. For the refraction services, you
did not see a preferred vision provider; therefore, no payment is due.
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 for
Medicare-covered vision care.
You have been asked to pay $20 for the medical eye exam. This service falls within the Medicare-covered
vision 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.
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 when they are rendered by a preferred vision provider.
We looked at the file and the Plan's rules. The file indicates that you received the eye refraction services from a
provider that is not a preferred vision provider. Based on this information, we decided that the Plan's rules for
coverage of eye refraction services have not been met. Therefore, we decided that the Plan does not have to
waive the copayment for the medical eye exam (92004) and does not have to pay for the eye refraction services
(92015) provided on October 22, 2020.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to waive or reimbursethe cost share for services provided on July 12, 2019.You asked the Plan to waive or reimbursefunds you believe were overpaid for services provided in 2019.You say that you believe you have overpaid the maximum out of pocket (MOOP) for 2019. The Plan denied your request. The Plan says the claims in question were reviewed. The Plans portion of the services in question have been paidfor each service leaving your contractual copayment of $50.00 for 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 in 2019 there was a maximum out of pocket of $4500. The Plan has provided claim and payment information for each service in question. Both the records and the Explanation of Benefits (that you would also have a copy of ) for each service clearly show the balance of the maximum out of pocket at the time of service. You have been asked to pay the correct amount for each service based on your contract with the Plan. This cost sharing is a contractual obligation you agreedto pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive or reimbursethe cost share for several claims for services provided on July 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to you by an out-of-network provider on September 29, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services were not authorized.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 services 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 forthe medical services provided to you by an out-of-network provider on September 29, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from April 9,
2020, to April 11, 2020.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you would like help
paying for the hospital services. 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 $275
copayment for days 1-6 for inpatient hospital care.
You had an inpatient hospital stay from April 9, 2020, to April 11, 2020. Therefore, you are responsible to pay
a $275 copayment for days 1-2 (April 9, 2020, to April 10, 2020). $275 (copayment) x 2 (inpatient days) =
$550.
You have been asked to pay the total copayment amount of $550 for an inpatient hospital stay. An inpatient
hospital stay 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 an inpatient hospital stay from April 9, 2020, to April 11, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe psychiatric diagnostic services rendered on April 2, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the claim was not filed timely.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.The record shows that a claim for these services was not filed until October 20, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay forthe psychiatric diagnostic services rendered on April 2, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an implant/abutment supported removable denture.

You asked the Plan to pre-approve the denture. The Plan denied your request. The Plan says this is not a
covered benefit.

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 services are not among
those covered under this benefit. The Plan covers only those dental services for which the codes are listed in
the Evidence of Coverage. Dental Code D6111 is not listed, and therefore, is not covered. Therefore, we
decided that the Plan does not have to pre-approve an implant/abutment supported removable denture.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe hospital discharge services rendered on May 22, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 99239 is not separately payable.The Plan must follow Medicare rules. The rules say that only one hospital discharge day management service is payable per patient per hospital stay. We looked at the file and Medicare rules. The file shows that procedure code 99239 was previously submitted for this enrollee on May 21, 2020. The discharge services billed on May 22, 2020 are not separately payable.Therefore, we decided that the Plan does not have to pay forthe hospital discharge services rendered on May 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a standard Group 2 Power Wheelchair (K0823).
You asked the Plan to pre-approve the standard Group 2 Power Wheelchair. You say that the power wheelchair
is medically necessary. The Plan denied your request. The Plan says the enrollee's weight exceeds the amount a
standard group 2 power wheelchair can support. A Heavy-Duty group 2 power wheelchair has been approved.
The Plan must follow Medicare rules. Medicare rules say that a Heavy Duty POV is covered for a beneficiary
weighing 285-450 pounds.
We looked at the file and Medicare rules. A standard group 2 power wheelchair supports up to 300 pounds. The
enrollee's weight is within 5% of capacity. A Heavy-Duty group 2 power wheelchair and accessories is more
appropriate and has already been approved by the plan. Based on this information, we decided that Medicare
rules for coverage of the standard Group 2 Power Wheelchair have not been met. Therefore, we decided that
the Plan does not have to pre-approve a standard Group 2 Power Wheelchair (K0823).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out of network referral to see a hematologist.

You asked the Plan to pre-approve an out of network referral to see a hematologist. You say that the requested out of network referral to see a hematologist is medically necessary for the diagnosis and treatment of waldenstrom macroglobulinemia.The Plan denied your request. The Plan says the requested out of network referral to see a hematologist is not medically necessary as there are in-network hematologists available.

Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care. 

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 an out of network referral to see a hematologist. Our reviewer says that the requested out of network referral to see a hematologist is not medically necessary as there are in-network hematologists available. Our physician reviewer found the enrollee is diagnosed with waldenstrom macroglobulinemia with symptoms. In this case, the enrollee can safely be treated by an in network specialist. This diagnosis is not unique and does not need tertiary level care. The requested out of network referral is not medically necessary at this time.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an out of network referral to see a hematologist have not been met.Therefore, we decided that the Plan does not have to pre-approve an out of network referral to see a hematologist.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ultrasound screening for abdominal aortic
aneurysms.
You asked the Plan to pre-approve an ultrasound screening for abdominal aortic aneurysms. You say that you
need this because you have abdominal pain and a hernia. The Plan denied your request. The Plan says you do
not meet the criteria for coverage.
The Plan must follow Medicare rules. Medicare rules say that an ultrasound screening for abdominal aortic
aneurysms is coved if you have a family history of an abdominal aortic aneurysm, are a man age 65 to 75 who
has smoked at least 100 cigarettes in his lifetime, or manifest other risk factors in a beneficiary category
recommended for screening by the United States Preventive Services Task Force regarding abdominal aortic
aneurysms, as specified by the Secretary through a national coverage determination process.
We looked at the file and Medicare rules. The record shows that you do not have a family history of abdominal
aortic aneurysms and have never smoked. There currently are not other benefit categories specified by nation
coverage determination. Based on this information, we decided that Medicare rules for coverage of an
ultrasound screening for abdominal aortic aneurysms have not been met. Therefore, we decided that the Plan
does not have to pre-approve an ultrasound screening for abdominal aortic aneurysms.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not
medically necessary.

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 admission to a LTACH is not medically necessary. Our physician reviewer found the
enrollee was admitted to the current acute care hospital with CVA. She was treated with an endarterectomy
complicated by another stroke and bleeding. Recent notes show that the enrollee remains quite weak on her left
side, has confusion, and has difficulty with speech and swallowing requiring Dobhoff tube feeds and therapy.

The records show that the enrollee is more stable but requires only short term additional acute care services
until stable for discharge to a lower level of care and when long-term feeding requirements are met. The
enrollee does not require services at the LTACH that are not already available at the current facility. There are
no services at the LTACH that are not already available and covered at the current facility. Therefore, this
request for LTACH services will be considered not medically necessary at this time.

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 long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on October 2, 2020.You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says thereis no authorization for this service and the provider is non-contract.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 Plandid not pre-approve the laboratory services. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for laboratory services provided on October 2, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forsurgical assistant services provided on July 14, 2020.You asked the Plan to pay forsurgical assistant services. You say that the primary surgeon and facility are in-network with the Plan and these services are payable to an assistant surgeon.The Plan denied your request. The Plan says the denial of payment for these services is correct, because Medicare does not allow payment for a Registered Nurse First Assistant (RNFA).The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS.In thiscase, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners.Therefore, we decided that the Plan does not have to pay forsurgical assistant services provided on July 14, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the immediate denture - mandibular (D5140), unspecified
removable prosthodontic procedure (D5899), extraction of erupted tooth (D7140), and extraction of erupted
tooth requiring removal of bone (D7210) provided on August 5, 2020.
You asked the Plan to pay for the immediate denture - mandibular, unspecified removable prosthodontic
procedure extraction, erupted tooth, and extraction, erupted tooth requiring removal of bone. You say that you
would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says you
have exhausted the benefit limit for the teeth extraction services and the immediate denture - mandibular and
unspecified removable prosthodontic procedure are not covered under your benefit.
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 the extraction
of the erupted tooth and extraction of erupted tooth requiring removal of bone 3 times per calendar year.
We looked at the file, and Medicare rules. The file indicates that they have covered 3 extraction procedures
performed August 5, 2020. This means that you have exhausted your benefit for extraction procedures. Based
on this information, we decided that the Plan's rules for coverage of the additional teeth extractions performed
on August 5, 2020, have not been met.
Though the Plan offers a dental benefit in excess of Medicare coverage, the immediate denture - mandibular
and unspecified removable prosthodontic procedure are not among those covered under this benefit. Therefore,
we decided that the Plan does not have to pay for the immediate denture - mandibular (D5140), unspecified
removable prosthodontic procedure (D5899), extraction of erupted tooth (D7140), and extraction of erupted
tooth requiring removal of bone (D7210) provided on August 5, 2020.