Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower
denture (D5120).
You asked the Plan to pre-approve a complete upper denture and a complete lower denture. You say that you
are requesting reconsideration. The Plan denied your request. The Plan says the benefit for these services is
exhausted per the dental contract.
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 complete
upper denture and a complete lower denture once every 60 months.
We looked at the file and Medicare rules. The records show that you received an immediate upper denture and
an immediate lower denture on February 24, 2021, therefore, you have exhausted your maximum benefit for
this service. Based on this information, we decided that the Plan's rules for coverage of a complete upper
denture and a complete lower denture have not been met. Therefore, we decided that the Plan does not have to
pre-approve a complete upper denture (D5110) and a complete lower denture (D5120).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cooled radiofrequency ablation (RFA).
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that non-thermal modalities for facet joint denervation
including chemical, low-grade thermal energy (less than 80 degrees Celsius), are denied.
We looked at the file and Medicare rules. The services at issue are cooled radiofrequency ablation (RFA).
These services are denied as not medically necessary. Therefore, we decided that the Plan does not have to preapprove
cooled radiofrequency ablation (RFA).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan you had on June 21, 2021.
You asked the Plan to waive the copayment for the CT scan. You say that you are being treated for kidney cancer and you were never told you were going to have to pay any portion of this. The Plan denied your request. The Plan says you were charged this copayment 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 $250 copayment for CT scans. You have been asked to pay a $250 copayment for the CT scan. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan you had on June 21, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for inpatient hospital services you received from May 3, 2021, to May 11, 2021.
You asked the Plan to waive the coinsurance for the inpatient hospital services. You say that you believe this coinsurance should be waived. You stated that this hospitalization was required due to a compromised immune system resulting from drug use for the treatment of COVID-19. You stated that because this stay was related to COVID-19, it should be covered with no cost sharing. 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 10% coinsurance for inpatient hospital services.
According to the Plan's website, cost sharing is not waived for COVID-19 treatment. The website explicitly states that if you get sick with COVID-19, cost sharing will be according to your benefit plan. You will be responsible for any copay, coinsurance, deductible, or out-of-network costs. This applies to Medicare Advantage members. You have been asked to pay 10% coinsurance for the inpatient hospital services. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for inpatient hospital services you received from May 3, 2021, to May 11, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services you received from May 18, 2021, to May 22, 2021.
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you thought your copayment would only be $325. You stated that you cannot pay this charge. The Plan denied your request. The Plan says you were charged this copayment 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 $300 copayment per day for days 1-5 for in-network inpatient hospital services. Records show that you were in the hospital for 4 days. You have been asked to pay a $300 copayment per day for each day, for a total of $1200. This means that you have been asked to pay the correct amount based on
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital services you received from May 18, 2021, to May 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the digital breast tomosynthesis you had on May 11, 2021.
You asked the Plan to waive the deductible for the digital breast tomosynthesis. You say that you believe your charge should be $0 for this service. The Plan denied your request. The Plan says you were charged this amount toward your deductible correctly.
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 $750 deductible which applies to diagnostic tests. The digital breast tomosynthesis falls within the benefit category diagnostic tests. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible which applies to diagnostic tests. The allowed amount of $5 for this service is what you are being charged towards your deductible This cost sharing is a contractual obligation that had not been met at the time the digital breast tomosynthesis was received on May 11, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the digital breast tomosynthesis you had on May 11, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on March 1, 2021.
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you do not understand the policy that the bill would be paid if you had been transported to the hospital, which would also involve a hospital bill. The Plan denied your request. The Plan says transportation is only covered when you are actually transported by ambulance. The Plan also says that since you were not transported by the ambulance, this service is not covered under your plan.
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 March 1, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on March 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyeglasses provided on March 16, 2021.
You asked the Plan to pay for the eyeglasses. You say that you should be receiving an additional $74.20 because you had not used any benefits until this point. You say that the claim should be reviewed to ensure it was processed properly. The Plan denied your request. The Plan says the annual amount allowed under your benefit was exceeded.
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 only covers one pair of eyeglasses with standard frames/lenses or one set of standard contact lenses after cataract surgery. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. The Plan paid for one pair of eyeglasses purchased on March 16, 2021, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the eyeglasses provided on March 16, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for coverage of IRF care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for a intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve surgical ventricular restoration.
You asked the Plan to pre-approve surgical ventricular restoration. You say that you strongly feel that surgery is warranted to fix the enrollee's condition. The Plan denied your request. The Plan says that the denial of authorization for this service is correct, because the available data is inadequate to permit conclusions regarding its health benefits.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. 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 surgical ventricular restoration. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a pseudoaneurysm of the left ventricle possibly related to a recent myocardial infarction which has been contained by the prior surgical adhesions. Although randomized data about the resection of chronic pseudoaneurysms is limited, the age of this pathology remains in question. More importantly, there is echocardiogram evidence that the pseudoaneurysm is increasing in size over the past 4 months, increasing the risk of ventricular rupture with certain lethal consequences or at least the development of heart failure as the pseudo-cavity size increases. Given this documented finding of increasing size, and based on the surgical recommendations and the enrollee's relatively low surgical risk, resection of the pseudoaneurysm is both medically reasonable and 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 surgical ventricular restoration have been met. Therefore, we decided that the Plan has to pre-approve surgical ventricular restoration.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the cytopathology provided on April 8, 2021.
You asked the Plan to pay for the cytopathology provided on April 8, 2021. You say that the service was medically necessary. The Plan denied your request. The Plan says that no prior authorization was obtained.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not show if the referring physician is an in-network or out-of-outwork provider. This means we are unable to determine if the Plan's denial of the non-emergent pathology service is supported. Therefore, we decided that the Plan has to pay for the cytopathology provided on April 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit services provided on June 14, 2021, and the
office visit, electrical stimulation, imaging, and physical therapy modalities provided on June 17, 2021, by a
chiropractor.
You asked the Plan to pay for the chiropractor services. You say that you were told this would be covered and
now have many bills for these services. The Plan denied your request. The Plan says Medicare only covers the
actual manual manipulation of the spine. All other services provided by chiropractors are noncovered.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation.
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided
that the Plan does not have to pay for the office visit services provided on June 14, 2021, and the office visit,
electrical stimulation, imaging, and physical therapy modalities provided on June 17, 2021, by a chiropractor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a peripheral nerve stimulator.
You asked the Plan to pre-approve a peripheral nerve stimulator. You say that the services are necessary. 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 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 peripheral nerve stimulator. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found this is not evidence-based therapy. There is no peer reviewed literature that
supports it is use for either Fibromyalgia or low back pain. The request is not medically reasonable or
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 a peripheral nerve stimulator have not been met. Therefore, we decided that the
Plan does not have to pre-approve a peripheral nerve stimulator.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for chemotherapy drugs you received on June 7, 2021.
You asked the Plan to waive the coinsurance for the chemotherapy drugs. You say that you believe you had met your maximum out-of-pocket prior to these services. The Plan denied your request. The Plan says as of the date this claim was processed (June 24, 2021), you had only met $3071.40 towards your maximum out-of-pocket amount. That is why 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 chemotherapy drugs. You have been asked to pay 20% coinsurance for the chemotherapy drugs. According to the Plan's records, you
had not yet met your maximum out-of-pocket amount when this claim was processed. 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 chemotherapy drugs you received on June 7, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient arthroplasty surgery you had at an outpatient hospital facility on June 21, 2021.
You asked the Plan to waive the copayment for the outpatient surgery. You say that this surgery was incorrectly considered outpatient because you stayed overnight. The Plan denied your request. The Plan says you were charged this copayment 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 $150
copayment for outpatient surgery in an outpatient hospital facility. You have been asked to pay a $150 copayment for the outpatient surgery. The billing records show that you were never formally admitted to the hospital as an inpatient and this surgery was done on an outpatient basis. You can be considered an outpatient even if you spend the night in the hospital. That is why the surgery you had falls within the outpatient surgery in an outpatient hospital facility 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 outpatient arthroplasty surgery you had at an outpatient hospital facility on June 21, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient hospital clinic visit you had on June 28, 2021.
You asked the Plan to waive the copayment for the outpatient hospital clinic visit. You say that you were not aware that there would be a facility fee for this. You stated that you are on a fixed income and you would have never gone to this appointment had you known. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that because the allowed amount for this service ($135.47) is less than your copayment obligation, you are responsible for the full allowed 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 $475 copayment for non-surgical visits to an outpatient hospital clinic. You have been asked to pay a $475 copayment for the outpatient hospital clinic visit. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the outpatient hospital clinic visit you had on June 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the wheelchair accessories coded as E0955, E0953, and
E0956 billed with the KU modifier provided on April 12, 2021.
You asked the Plan to pay for the wheelchair accessories. You say that you would like these claims approved.
The Plan denied your request. The Plan says an incorrect modifier has been submitted for these items.
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 codes E0955, E0953, and E0956 are not supported in the medical record. Specifically, these
claims have been billed with the KU modifier. This modifier is only to be used when the wheelchair
accessories are being furnished in connection with a manual wheelchair. The wheelchair in question in this case
is a power operated wheelchair. Based on this information, we decided that Medicare rules for coverage of the
wheelchair accessories have not been met. Therefore, we decided that the Plan does not have to pay for the
wheelchair accessories coded as E0955, E0953, and E0956 billed with the KU modifier provided on April 12,
2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve out-of-network physical therapy.
You asked the Plan to pre-approve out-of-network physical therapy. You say that you have no car and nobody to go with you for physical therapy. You say that this provider is on site and you will be trapped in your apartment without immediate therapy. The Plan denied your request. The Plan says in-network providers are available. The Plan also says that home health physical therapy is available if you are homebound.
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 out-of-network physical therapy.