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

We decided that the Plan does not have to waive the copayment for an electrocardiogram (EKG) provided on August 16, 2021.
You asked the Plan to waive the copayment for an EKG. You say that the billing was wrong and not done in an outpatient hospital. The Plan denied your request. The Plan says the proper copayment was applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 copayment for Medicare-covered non-radiological diagnostic services. The total amount allowed was $15.61 which is less than the copayment amount of $20.
You have been asked to pay a $15.61 copayment for an EKG. An EKG 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 an electrocardiogram (EKG) provided on August 16, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for treatment by a specialist and the coinsurance for a chemotherapy drug and the administration of the drug on May 6, 2021.
You asked the Plan to waive the copayment for treatment by a specialist and a coinsurance for a chemotherapy drug and the administration of the drug. You say that previous treatment was covered. The Plan denied your request. The Plan says the proper copayment and coinsurance was applied
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan also clearly says that you must pay a 20% coinsurance for each Medicare-covered chemotherapy drug and the administration of that drug. The amount allowed for the chemotherapy drug was $1373.58.
The coinsurance amount was $274.72 ($1373.58 x 20% coinsurance). The amount allowed for the administration of the chemotherapy drug was $31.16. The coinsurance amount was $6.23 ($31.16 x 20% coinsurance).
Your contract with the Plan also clearly says that you must pay a $25 copayment for services obtained from a specialist.
You have been asked to pay a 20% coinsurance for the chemotherapy drug and the administration of the drug. The chemotherapy drug and the administration of the drug falls within the Medicare Part B Prescription Drugs benefit category. You have also been asked to pay a $25 copayment for services obtained from a specialist. The services obtained from a specialist falls within the Medicare covered Physician/Practitioner 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 treatment by a specialist and the coinsurance for the chemotherapy drug and the administration of the drug on May 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyeglasses purchased on February 12, 2021.
You asked the Plan to pay for the eyeglasses. You say that you were not told that you could only use this benefit once every two years. The Plan denied your request.
The Plan says you previously used your eyewear benefit in September 2019, which is less than two years before February 12, 2021. Therefore, your eyewear benefit was exhausted on the date in question, and the services are denied.
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 up to $150 for eyewear every two years. We looked at the file and the Plan's rules. Documentation shows that you previously exhausted this benefit in September 2019, which is less than two years prior to the date in question. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for the eyeglasses purchased on February 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for a specialist office visit (99203) and the
destruction of skin growth (17110) provided on September 7, 2021.
You asked the Plan to waive the deductible for a specialist office visit and the destruction of skin growth. You
say that The services should be covered since you were referred to the specialist by your primary care
physician. The Plan denied your request. The Plan says the deductible applied correctly based on the services
provided.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that there is a $500 deductible which applies to Physician/Practitioner Services,
Including Specialists Doctor's Office Visits. The Plan did not deny the services, services rendered by a
specialist are not exempt from the deductible.
The item or service you asked the Plan to waive the deductible for falls within the benefit category
Physician/Practitioner Services, Including Specialists Doctor's Office Visits. The Plan has followed Medicare
rules by clearly disclosing in the contract that there is a $500 deductible which applies to Physician/Practitioner
Services, Including Specialists Doctor's Office Visits. This cost sharing is a contractual obligation that had not
been met at the time the specialist office visit and the destruction of skin growth was received on September 7,
2021. Therefore, we decided that the Plan does not have to waive the deductible for a specialist office visit
(99203) and the destruction of skin growth (17110) provided on September 7, 2021, therefore the charges
totaling $220.49 will remain.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90832) provided on June 30, 2021.
You asked the Plan to pay for psychotherapy services. You say that the services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan must follow Medicare rules. Medicare rules say that the CP will attempt to consult with the enrollee's attending or primary care physician.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of psychotherapy services have not been met. Specifically, the provided records do not document an
attempt to consult with, nor a referral from, the enrollee's attending or primary care physician. Therefore, we
decided that the Plan does not have to pay for psychotherapy services (90832) provided on June 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the resin-based composite (D2392) and crown (D2740) provided on October 5, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay more for the resin-based composite and crown. You say that you were advised that these services would be covered in full. You also say that you were not told that this treating provider was OON. The Plan denied your request. The Plan says these services were performed by an OON provider, and you are responsible for any difference between the Maximum Allowable Fee and the amount the provider bills you for the services. The Plan also says that you did not contact the Plan prior to this date of service to verify benefits and provider eligibility.
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, you are responsible for the difference between the billed amount and allowed amount because these services were received OON. Therefore, we decided that the Plan does not have to pay more for the resin-based composite (D2392) and crown (D2740) provided on October 5, 2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan of the brain (70450) provided on September 2, 2021.
You asked the Plan to waive the copayment for the CT scan of the brain. You say that the services should be covered as you feel you should not owe anything for the surgery, The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $135 copayment for Outpatient hospital services.
You have been asked to pay a $130.15 copayment for the CT scan of the brain, which is less than the $135 stated in the Plan's contract. CT scans of the brain fall 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 waive the copayment for a CT scan of the brain (70450) provided on September 2, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for x-ray examination of the abdomen (74018, R0070, Q0092) provided on August 18, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for x-ray examination of the abdomen. You say that the patient's doctor ordered the x-rays, and you are contracted with the doctor to provide x-ray service to his practice patients. You also say you are unable to get authorizations for these patients as once you receive the demographic information, it is too late for the authorization as the x-ray has already been taken. The Plan denied your request. The Plan says this provider is a non-participating provider with the Plan and the member was referred by a non-participating provider. The Plan also says that they have also determined that these services are not urgent or emergent, nor were they approved in advance.
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 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 x-ray examination of the abdomen (74018, R0070, Q0092) provided on August 18, 2021, by an out-of-network (OON) provider
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral hygiene instruction (D1330), and 2D photographic images (D0350 x 4) provided on July 15, 2021.
You asked the Plan to pay for the oral hygiene instructions and 2D photographic images. You say that the dental office advised they were in network. You say that you were not aware that you were seen by an out of network dentist. You say that you requested a basic cleaning and extraction. You also say that you expected better service. The Plan denied your request. The Plan says oral hygiene instructions and 2D photographic images are not listed as covered dental 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 oral hygiene instruction and 2D
photographic images are not among those covered under this benefit. Therefore, we decided that the Plan does
not have to pay for the oral hygiene instruction (D1330), and 2D photographic images (D0350 x 4) provided on
July 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for knee scooter provided on May 20, 2021.
You asked the Plan to waive the coinsurance for the knee scooter. You say that you had knee surgery and your doctor requested a knee scooter for recovery. The Plan denied your request. The Plan says the correct coinsurance was applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for each durable medical equipment (DME) item, including knee scooters. The file shows that the Plan has reimbursed $115.19, which is the Plan's 80% responsibility ($143.99 allowed amount x 80% Plan responsibility = $115.19). Therefore, you are responsible for $28.80, which is the remaining 20% of the allowed amount for the knee scooter ($143.99 allowed amount x 20% coinsurance = $28.80). The knee scooter falls within the Durable Medical Equipment (DME) and Related 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 coinsurance for knee scooter provided on May 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on October 4, 2021.
You asked the Plan to pay for the periodontal maintenance. You say that this is the first time you used this Plan for a dental cleaning. The Plan denied your request. The Plan says the number of occurrences this procedure was performed has exceeded the contract limits.
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, you are limited to up to 2 cleanings per year. The record shows that you received cleanings on March 1, 2021, and June 2, 2021 and your cleanings benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on October 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary visit provided on April 26, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the domiciliary visit. You say that the provider relies on the facility staff to verify eligibility and obtain authorization. You say the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the domiciliary visit provided on April 26, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the temporary balloon arterial occlusion (61623) provided on January 11, 2021.
You asked the Plan to pay for the temporary balloon arterial occlusion (61623). You say that per the coding review this is coded correctly, and the service was medically necessary. You say that the service was provided with the expectation of payment and should be processed for payment. The Plan denied your request. The Plan says procedure code 61623 is not supported by the medical records submitted.
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 61623 is endovascular temporary balloon arterial occlusion, head or neck (extracranial/intracranial) including selective catheterization of vessel to be occluded, positioning and inflation of occlusion balloon, concomitant neurological monitoring, and radiologic supervision and interpretation of all angiography required for balloon occlusion and to exclude vascular injury post occlusion. We asked our coder 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 temporary balloon arterial occlusion (61623). Our reviewer says that the documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found that the procedure report does not support a temporary balloon arterial occlusion. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the temporary balloon arterial occlusion (61623) have not been met. Therefore, we decided that the Plan does not have to pay for the temporary balloon arterial occlusion (61623) provided on January 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on July 27, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the office visit. You say that you have never needed prior authorization for an office visit. The Plan denied your request. The Plan says no prior authorization was obtained.
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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the services at issue were urgent or emergent. Therefore, we decided that the Plan does not have to pay for the office visit provided on July 27, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit, hearing aid supplies and sales tax provided from January 24, 20191, through November 16, 2020.
You asked the Plan to pay for the office visit, hearing aid supplies and sales tax. You say that you were not aware that reimbursement for hearing aids, batteries and office visits could be claimed. You say that you just found out they could be claimed, and the denial should be reconsidered. The Plan denied your request. The Plan says you have 12 months from the date of service to submit claims.
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 rules also say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.
The record shows that the claim for the office visit, hearing aid supplies and sales tax provided through July 20, 2020, were not filed until October 21, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. The office visit provided on November 16, 2020, was filed timely but medical records were not submitted to determine if coverage criteria have been met. Therefore, we decided that the Plan does not have to pay for the office visit, hearing aid supplies and sales tax provided from January 24, 20191, through November 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the determination of refractive state (92015) provided
October 25, 2021.
You asked the Plan to pay for the eye refraction. You say that this is a standard test and should be covered as
part of a routine exam. The Plan denied your request. The Plan says the refraction was performed as part of a
medical eye exam and therefore it is not covered.
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 performed as part of a routine eye exam.
We looked at the file and the Plan's rules. The medical record shows that the eye exam was provided to treat a
medical problem and was not a routine eye exam. Based on this information, we decided that eye refraction is
not a covered service. Therefore, we decided that the Plan does not have to pay for the determination of
refractive state (92015) provided October 25, 2021.
Your complaint about how services are billed and non-coverage of this service when provided during a medical
eye exam 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a MyoPro 2 Motion G device.
You asked the Plan to pre-approve a MyoPro 2 Motion G device. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the requested device is not medically
necessary.
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 a MyoPro 2 Motion G device. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found the enrollee has a past medical history of stroke with left upper extremity
weakness. There is no documentation that the MyoPro 2 Motion G device at issue in this case meets Medicare
criteria for medically reasonable and necessary. Current clinical guidelines designate robotic therapy to be of
"uncertain utility compared with dose-matched conventional upper limb exercise therapies" with unproven
benefit in the home environment. Therefore, the enrollee does not meet criteria for the requested item.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a MyoPro 2 Motion G device have not been met. Therefore, we decided that the
Plan does not have to pre-approve a MyoPro 2 Motion G device.