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

We decided that the Plan does not have to pre-approve use of Botox (botulinum toxin).
You asked the Plan to pre-approve Botox. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this request is not being made for a medically-accepted indication.
The Plan follows Medicare rules. Medicare rules state that Botox may only be covered for certain indications. 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 Botox. Our reviewer says that the
enrollee does not meet the Medicare criteria for the requested use of Botox. Our physician reviewer found based on the records provided, there is no documentation that the enrollee meets the criteria for coverage of Botox for limb dystonia due to Parkinson's Disease. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Botox (botulinum toxin).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids (V5261) provided on December 9, 2019, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for hearing aids. You say that you are requesting reconsideration for payment of this 
claim. The Plan denied your request. The Plan says there is no coverage if hearing aids, or related services are 
received from an out-of-network provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for 
hearing aids only when provided by the Plan's hearing aid provider.  
 
We looked at the file and the Plan's rules. The records show that the hearing aids were provided by an OON 
provider. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been 
met. Therefore, we decided that the Plan does not have to pay for hearing aids (V5261) provided on December 
9, 2019, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electrical connection for a power wheelchair 
(E2311). 
 
You asked the Plan to pre-approve the item. You say that this is medically necessary. The Plan denied your 
request. The Plan says this item may be covered for people who have a power wheelchair with multiple seat 
functions. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the item. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the documentation does not indicate that you need to operate multiple functions on the power 
wheelchair. You do not need to operate 3 or more powered seating actuators through the drive control. The 
power tilt, recline, and power elevating leg rests were denied as not medically necessary therefore the power 
connection controller E2311 is 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 item have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an electrical connection for a power wheelchair (E2311).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says all the services that are needed are offered at the inpatient rehabilitation facility.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the admission. Our reviewer says that the requested admission is not medically reasonable or necessary. Our physician reviewer found there no identifiable skilled nursing service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) 
provided on May 29, 2021. 
 
You asked the Plan to pay for the ambulance service. You say that the all the provider did was take your vital 
signs and then left. You say that you cannot afford the charges. You also say that you would like the claim paid 
or charges to be reduced. The Plan denied your request. The Plan says if you refuse transport when an 
ambulance is dispatched, you will be responsible for the full cost of the service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on May 29, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
The record shows that you signed a release form acknowledging that you refused transport. Therefore, we 
decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) 
provided on May 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950) provided on June 24, 2021.
You asked the Plan to pay for the core buildup. You say that you received a temporary filling, and not a core buildup. You also say that you should not be held responsible for the charge. The Plan denied your request. The Plan says that they confirmed with the treating provider that you did receive a core buildup, and not a temporary filling. The Plan also says that core buildup 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, 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 core buildup, including any pins when required (D2950) provided on June 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reimburse for the services you received from December 28, 2020, to 
February 20, 2021. 
 
You asked the Plan to reimburse for the services. You say that the services were urgent. The Plan denied your 
request. The Plan says the claim 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 $40 
copayment for each Medicare-covered urgent care visit worldwide.  
 
Review of the file shows that you were provided foreign medical services from December 28, 2020, to 
February 20, 2021. The services fall within the urgent 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 reimburse for the services you received from December 28, 2020, to 
February 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a physical medicine and rehabilitation 
office visit provided on June 12, 2021. 
 
You asked the Plan to waive the copayment for specialist visit. You say that you do not agree with this charge. 
The Plan denied your request. The Plan says the copayment amount you are being charged is correct. 
 
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 $45 
copayment for each specialist visit.  
 
You have been asked to pay $45 copayment for specialist visit. Specialist visit falls within the 
Physician/Practitioner Services, Including Doctor's Office Visits benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for a physical medicine and rehabilitation office visit provided on June 12, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided from May 24, 2021, to May 29, 2021.
You asked the Plan to pay for the self-administered drugs. You say that you did not administer any drugs that were ordered for you by the medical staff. The Plan denied your request. The Plan says self-administered drugs are not covered under Part B of Original Medicare.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs provided from May 24, 2021, to May 29, 2021.
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and a complete series of radiographic images (D0210) provided on February 17, 2021.
You asked the Plan to pay for a comprehensive oral evaluation and a complete series of radiographic images. You say that you needed to see the provider as soon as possible due to a medical necessity. The Plan denied your request. The Plan says the services at issue are covered once every three years.
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 a comprehensive oral evaluation and a complete series of radiographic images once every three plan years.
We looked at the file and Medicare rules. The records show you received a comprehensive oral exam and a complete series of radiographic images on November 20, 2018; therefore, you have exhausted your maximum benefit for these services. Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral evaluation and a complete series of radiographic images have not been met. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and a complete series of radiographic images (D0210) provided on February 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the four gingival irrigations (D4921 x4) or pay more for the three periodontal scalings and root planings of four or more teeth per quadrant (D4341 x3) and periodontal scaling and root planing of one to three teeth per quadrant (D4342) provided on May 19, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the gingival irrigations and to pay more for the scalings and planings. You say that when you gave copies of your insurance cards to the clerk, you were advised that everything was covered. You also say that you advised them that you did not want to be responsible for any charges. The Plan denied your request. The Plan says gingival irrigation is not a covered service. The Plan also says that these services were performed by a non-participating provider, and you are responsible for any difference between the Maximum Allowable Fee and the amount the provider bills you for the 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, gingival irrigation is not among those covered under this benefit. You are also responsible for the difference between the billed amount and allowed amount for covered dental services that are received OON. Therefore, we decided that the Plan does not have to pay for the four gingival irrigations (D4921 x4) or pay more for the three periodontal scalings and root planings of four or more teeth per quadrant (D4341 x3) and periodontal scaling and root planing of one to three teeth per quadrant (D4342) provided on May 19, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the vitamin injections (J3490 and J7999) provided on
December 9, 2020.
You asked the Plan to pay for the vitamin injections. You say that you would like the Plan to reconsider their
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the vitamin injections have not been met. The drug code reported on this claim refers to a pre-filled
compounded drug/vitamin syringe. The rules require that any compounded drug be billed using the not
otherwise classified code J7999. As this compounded drug was not billed properly, payment cannot be made.
Therefore, we decided that the Plan does not have to pay for the vitamin injections (J3490 and J7999) provided
on December 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the manual wheelchair you rented from 
January 3, 2021, to August 3, 2021. 
 
You asked the Plan to waive the coinsurance for the manual wheelchair. You say that no one told you that the 
cost for this item could change year to year. You said the coinsurance has gone up in 2021. The Plan denied 
your request. The Plan says you were charged this coinsurance 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 durable medical equipment.  
 
You have been asked to pay 20% coinsurance for the manual wheelchair. The manual wheelchair falls within 
the durable medical equipment benefit category. This coinsurance is based on the allowed amount in effect at 
the time of each monthly rental. 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 manual wheelchair you rented from 
January 3, 2021, to August 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete series x-ray (D0210) provided on June 17, 2021.
You asked the Plan to pay for the oral evaluation and complete series x-ray. You say that you were advised the provider in this case was in network. You also say that the provider was listed as in network online. The Plan denied your request. The Plan says 1 comprehensive oral evaluation is covered every 3 years. The Plan says that 1 complete series x-ray is covered every 5 years. The Plan also says that the frequency limits have been exceeded.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage and the services are listed as covered, the frequency limits have been exceeded. The record shows that the Plan paid for a comprehensive oral evaluation and complete series x-ray that you received on December 1, 2020. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete series x-ray (D0210) provided on June 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for additional supplies, materials, and staff time (99072) 
provided on January 19, 2021. 
 
You asked the Plan to pay for additional supplies, materials, and staff time. You say that this claim was 
processed incorrectly by the Plan. The Plan denied your request. The Plan says the denial of payment for this 
service is correct, because code 99072 is always bundled for payment and is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that code 99072 is always bundled for payment and is 
not separately payable.  
 
We looked at the file and Medicare rules. This code is always bundled for payment and is not separately 
payable. Based on this information, we decided that Medicare rules for coverage of additional supplies, 
materials, and staff time have not been met. Therefore, we decided that the Plan does not have to pay for 
additional supplies, materials, and staff time (99072) provided on January 19, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient services provided from June 20, 2020, through  
June 25, 2020 with the reported principal diagnosis A41.9, sepsis, unspecified organism. 
 
You asked the Plan to pay for inpatient services provided from June 20, 2020, through June 25, 2020 with the 
reported principal diagnosis A41.9, sepsis, unspecified organism. The Plan denied your request. The Plan says 
according to coding guidelines and documentation in the medical record this condition did not qualify for 
reporting the principal diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with A41.9, sepsis, unspecified organism. We asked our 
physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for inpatient services provided with the reported principal 
diagnosis A41.9, sepsis, unspecified organism. Our reviewer says that the documentation does not support that 
the inpatient care is payable as billed. Our physician reviewer found that the documentation consisted of 
several pages of nursing documentation, laboratory report, and electrocardiography (EKG). No documentation 
was found to support a qualified provider documented a diagnosis and treatment of sepsis. Documentation to 
support a diagnosis should be initial and subsequent hospital care, with supporting testing. This diagnosis 
cannot be confirmed by documentation submitted. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient services provided from June 20, 2020, through June 25, 2020 with the reported principal diagnosis 
A41.9, sepsis, unspecified organism.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for the emergency ambulance services (A0429 and A0425) provided on 
January 25, 2021. 
 
You asked the Plan to pay for the emergency ambulance services. You say that you would like reconsideration 
because you would not have called an ambulance if it was not an emergency. The Plan denied your request. 
The Plan says that the ambulance services were not medically necessary. 
 
Medicare pays for ambulance services only when an emergency exists or when other means of transport would 
endanger the patient's health. The Plan follows the same rules.  
 
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 the emergency ambulance services. Our reviewer says that the member's presenting symptoms met 
prudent layperson criteria for emergency care. Our physician reviewer found you have a history of multiple 
conditions and had ongoing chronic back pain. 
 
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 emergency ambulance services have been met. Therefore, we decided that 
the Plan has to pay for the emergency ambulance services (A0429 and A0425) provided on January 25, 2021.  
 
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.