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

We decided that the Plan does not have to waive the coinsurance for the Botox injections provided on December 9, 2019.
You asked the Plan to waive the coinsurance for the Botox injections. You say that you paid the copayment and weren't informed of the extra cost. You say that you cannot afford this. The Plan denied your request. The Plan says the coinsurance 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 in-network Medicare Part B Covered drugs. You have been asked to pay $244.80, which is 20% of the allowed amount for the Botox injections. The allowed amount is $1,224 (20% x $1,224 = $244.80). The Botox injections fall within the "Medicare Part B prescription drugs" 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 coinsurance for the Botox injections provided on December 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for moderate sedation services (99153) provided on December 17, 2019.
You asked the Plan to pay for moderate sedation services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says as CPT code 99153 is a technical component only code, it should be reported by a MAC Part A or B hospital setting.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 99153 is not supported in the record. Specifically, CPT code 99153 is a technical component only code. The record indicates that the member is in an outpatient hospital facility. This means that the facility should report this service and is responsible for payment to any vendor. Based on this information, we decided that Medicare rules for coverage of moderate sedation services have not been met. Therefore, we decided that the Plan does not have to pay for moderate sedation services (99153) provided on December 17, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 27365 provided on October 4, 2019.
You asked the Plan to pay for CPT code 27365. You say that the medical records support the billing of CPT code 27365. The Plan denied your request. The Plan says the medical records do not support the billing of CPT code 27365.
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 27365 is Radical resection of tumor, femur or knee. 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 CPT code 27365. Our reviewer says that the medical records do not support the billing of CPT code 27365. Our physician reviewer found the documentation submitted was reviewed. The operative note does not report that a Radical resection of tumor, femur or knee was performed and the submitted code cannot be verified. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CPT code 27365 have not been met. Therefore, we decided that the Plan does not have to pay for CPT code 27365 provided on October 4, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on November
27, 2019.
You asked the Plan to waive the copayment for ambulance services. You say that you didn't make the call and
you weren't transported to the hospital. You say that you are not paying. The Plan denied your request. The
Plan says the copayment 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 $200 for
each non Medicare-covered ambulance stabilization when there is no transport.
You have been asked to pay a $200 copayment for the ambulance services. Ambulance services fall within the
"Ambulance services" 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 ambulance
services provided on November 27, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to providea home blood pressure monitor.You asked the Plan to providea home blood pressure monitor. You say that you have high blood pressure and your monitor stopped working.The Plan denied your request. The Plan says home blood pressure monitors are only for enrollees on home dialysis.The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require ABPM to confirm a diagnosis of hypertension. The records do not show that this monitor is requested in the setting of home dialysis services, or that this request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation.Therefore, we decided that the Plan does not have to providea home blood pressure monitor.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the assistant surgeon services provided on December 19, 2019.
You asked the Plan to pre-approve the services. The Plan denied your request. The Plan says assistant surgeon services are not covered for this procedure.
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for CPT code 45378. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the services have not been met. Therefore, we decided that the Plan does not have to pre-approve the assistant surgeon services provided on December 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a FreeStyle Libre Continuous Glucose Monitoring System. You asked the Plan to pre-approve a continuous glucose monitor. You say that the enrollee needs a CGM for better control of blood glucose levels. The Plan denied your request. The Plan says a CGM is not covered by Medicare when an enrollee is not on insulin.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. The enrollee is not insulin treated so the Medicare coverage criteria for a CGM is not met. Based on this information, we decided that Medicare rules for coverage of a continuous glucose monitor have not been met.Therefore, we decided that the Plan does not have to pre-approve a FreeStyle Libre Continuous Glucose Monitoring System.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to payforthe acute inpatient hospital care provided from January 31, 2019 to February 4, 2019.You asked the Plan to pay foracute inpatient hospital care. You say that you are appealing with medical records.The Plan denied your request. The Plan says that the denial of payment for these services is correct, because this hospital stay did not meet inpatient criteria and should have been billed as outpatient.The Plan must follow Medicare rules. 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 twomidnights 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 the enrollee presented to the emergency department on January 31, 2019. She was evaluated and admitted to the hospital for further management. The enrollee was discharged in stable condition on February 4, 2019 when considered medically stable with follow-up with her primary care physician. The record shows that at the time of inpatient admission the admitting physician reasonable expected that the enrollee's necessary hospital care (including earlier emergency department and/or observation care) would span at least 2 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 forthe acute inpatient hospital care provided from January 31, 2019 to February 4, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyewear purchased on November 21, 2019 from an out-of-network provider.
You asked the Plan to pay for the eyewear. You say that your EOC booklet says that you can get covered eyewear from in-network or from out-of-network providers and if you get eyewear out-of-network, you will need to pay for the eyewear and submit a claim to the plan and request reimbursement of your allowance listed above. The Plan denied your request. The Plan says the decision is based on your 2019 EOC. The Plan states your 2020 benefits allow for out-of-network provider, but not your 2019 benefits.
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.
We looked at the file and the Plan's rules. Review of the file show that you purchased eyewear on November 21, 2019 from an out-of-network provider. Your 2019 EOC states, "you can use this allowance toward the purchase price of eyewear from a plan optical facility when a physician or optometrist prescribes an eyeglass or contact lens for vision correction. The allowance can be used for the following items: Eyeglass lenses when a network provider puts the lenses into a frame. Eyeglass frames when a network provider puts two lenses (at least one of which must have refractive value) into the frame. Contact lenses, fitting, and dispensing." Therefore, we decided that the Plan does not have to pay for the eyewear purchased on November 21, 2019 from an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc injections (J7325).
You asked the Plan to pre-approve Synvisc injections. You say that the services are necessary to help with the pain until you are able to get knee surgery. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Synvisc injections (J7325).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bathtub grab bars.
You asked the Plan to pre-approve grab bars. You say that you need assistance with showering and using the restroom. The Plan denied your request. The Plan says that this 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 grab bars 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 pre-approve bathtub grab bars.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment forthe cystoscopy provided on March 12, 2020.You asked the Plan to reduce the copayment forthe cystoscopy. You say that you should be charged the difference of the fee charge or the allowed fee and the insurance payment. You say you should be charged whichever is less. 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 $225 copayment for each in-network Medicare-covered hospital facility visit. You have been asked to pay a $225 copayment for the cystoscopy. The cystoscopy falls within the "Outpatient hospital services" 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 reduce the copayment forthe cystoscopy provided on March 12, 2020.Your complaintthat the billing practice seems illogical and illegal 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ambulance transport provided on December 21, 2019.You asked the Plan to waive the copayment forthe ambulance transport. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request.The Plan denied your request. The Plan says you received an ambulance transport on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.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 $200 copayment for Ambulance services. We looked at the file, the Plan's contract and Medicare rules. The file shows you were transported by ambulance on December 21, 2019. You have been asked to pay a $200 copayment for the ambulance transport. The ambulance transport falls within the Ambulance services 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 forthe ambulance transport provided on December 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee does 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 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 a referral to an out-of-network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve air ambulance services.
You asked the Plan to pre-approve the air ambulance services. You say that you requested a voluntary
discharge to another facility, as you had concerns with the quality of care at the original treating facility. The
Plan denied your request. The Plan says the criteria for coverage have not been met.
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your
medical condition is such that transportation by ground ambulance is not appropriate.
We looked at the file and Medicare rules. There was no documentation submitted to show that the enrollee's
current clinical condition requires emergency transportation that cannot be provided by ground transportation.
Based on this information, we decided that Medicare rules for coverage of the air ambulance services have not
been met. Therefore, we decided that the Plan does not have to pre-approve air ambulance services
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the orthoses provided on November 27, 2019.
You asked the Plan to pay for the orthoses. You say that you would like the plan to reconsider their denial. The
Plan denied your request. The Plan says the items rendered are not supported by the documentation.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services,
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for
telehealth services only if they are presented from an authorized originating site located in either a county
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located
in a rural census tract.
A review of the file does not support any evidence of an established relationship between the enrollee and the
ordering physician. Also, the documentation does not show that the telehealth service was provided in an
authorized originating site. This means that the telehealth visit is not a covered service under the Medicare
program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following
the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for the
orthoses provided on November 27, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiographic implant (D6190), the cone beam CT capture and interpretation (D0364), and the endosteal implants (D6010 x 4) provided from December 17, 2019 to January 29, 2020.
You asked the Plan to pay for the implants and CT scan. You say that you have not been able to wear your dentures. You say that the bone in your gums is deteriorating. You say that the implants will stimulate bone growth and prevent bone loss. You also say that without the implants, you are unable to wear your dentures. The Plan denied your request. The Plan says the radiographic implant, CT capture and interpretation, and implants are not listed as covered services.
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 radiographic implant (D6190), the cone beam CT capture and interpretation (D0364), and the endosteal implants (D6010 x 4) provided from December 17, 2019 to January 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pulse oximeter.
You asked the Plan to pre-approve the oximeter. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that oximeters will be denied as non-covered because they are monitoring devices that provide information to physicians to assist in managing the beneficiary's treatment. The requested item is statutorily not covered by Medicare at this time. Based on this information, we decided that Medicare rules for coverage of the oximeter have not been met. Therefore, we decided that the Plan does not have to pre-approve a pulse oximeter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe core build up (D2950), and 2 porcelain fused crowns (D2740) providedon August 8, 2020.You asked the Plan to pay forthe dental services. You say that the enrollee has Sjogren's disease. You say that the enrollee experiences severe pain and has not been able to eat or drink normally. You also say that you are trying to save as many of the enrollee's teeth by completing needed dental work.The Plan denied your request. The Plan says the core build up is not listed as a covered service. The Plan also says the porcelain crowns are not listed as covered services.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 core build up and crowns are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe core build up (D2950), and 2 porcelain fused crowns (D2740) provided on August 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay fordetermination of refractive state (CPT Code 92015) provided on January 27, 2020.You asked the Plan to pay forthe eye refraction. You say that you are appealing for reconsideration of the denied charges.The Plandenied your request. The Plan says this item is not covered under Medicare.The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. After thoroughly reviewing your case file the Plan has determined the eye refraction service that was provided on January 27, 2020 is not a covered benefit since it was a medical vision check (Myopia and Bilateral). Eye refractions are only covered by your plan is performed by a participating provider and performed as a routine screening per your EOC.Therefore, we decided that the Plan does not have to pay fordetermination of refractive state (CPT Code 92015) provided on January 27, 2020.