Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the diabetic test strips (A4253) and lancets (A4259), provided on March 26, 2021.  You asked the Plan to pay for the diabetic test strips and lancets. You say that the items should be covered. The Plan denied your request. The Plan says diabetic monitors and test strips received from a nonpreferred manufacturer are not covered.  The Plan must follow Medicare rules. Medicare rules say that MA plans may specify brands and manufacturers as preferred and charge lower cost-sharing for the preferred brands or may limit the Durable Medical Equipment (DME) to only those preferred brands and manufacturers.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the diabetic test strips and lancets have not been met. Therefore, we decided that the Plan does not have to pay for the diabetic test strips (A4253) and lancets (A4259), provided on March 26, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a CT scan provided on June 7, 2021.  You asked the Plan to waive the copayment for a CT scan. You say that your physician recommended you to have a CT scan every 3-4 months and you disagree with the denial of charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 copayment for CT scans.   You have been asked to pay a $100 copayment for a CT scan. A CT scan falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a CT scan provided on June 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the abutment-supported crown (D6059) provided on August 4, 2021.  You asked the Plan to pay for the abutment-supported crown. You say that you understood that crowns were covered with 25% coinsurance, and the brochure you received from the Plan did not provide information about dental codes. The Plan denied your request. The Plan says abutment-supported crowns are not covered by your dental benefit.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan can cover crowns for permanent teeth, once every 84 months per tooth, with codes D2710-D2794.  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. The Plan covers only traditional crowns which are supported by the root structure of the natural tooth to which it has been applied. These services are defined with codes D2710-D2794. Abutment-supported crowns are supported and stabilized by an abutment on an implant and require different work to be done. Because this type of crown requires an implant and abutment, it is considered an implant service. Non-traditional crowns and implant services are not listed as covered by the Plan. Documentation also does not indicate that a call was made to the Plan to verify benefits prior to services. Therefore, we decided that the Plan does not have to pay for the abutment-supported crown (D6059) provided on August 4, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for outpatient rehabilitation services provided on March 16, 2021.  You asked the Plan to waive the copayment for outpatient rehabilitation services. You say that you disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for outpatient rehabilitation services.   You have been asked to pay a $40 copayment for outpatient rehabilitation services. Outpatient rehabilitation services fall within the outpatient rehabilitation 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 outpatient rehabilitation services provided on March 16, 2021.
Appeal type: Outpatient Mental Health
Decision: Favorable

 We decided that the Plan has to pay for the individual psychotherapy services (90832) provided June 22, 2021.  You asked the Plan to pay for the psychotherapy services. You say that you have attached the medical record for processing the claim. Please review the attached document and process the claim toward payment. The Plan denied your request. The Plan says that there is no documentation of the required consultation with the attending or primary care physician in the enrollee's medical records. The listing of a referring provider on the claim does not satisfy the documentation criteria.  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 looked at the file, your request and Medicare rules. Based on this information we have decided that the rules for Medicare coverage of the psychotherapy services have been met. The submitted claim includes a referring provider for the services at issue. Documentation of a physician consultation does not apply when the physician has referred the beneficiary to the clinical psychologist. Therefore, we decided that the Plan has to pay for the individual psychotherapy services (90832) provided June 22, 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.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the insertion of a Sprint Peripheral Verve Stimulator (PNS) System (64555).  You asked the Plan to pre-approve the insertion of a Sprint PNS System. You say that this is medically necessary. The Plan denied your request. The Plan says this is experimental.  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 insertion of a Sprint PNS System. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is considered an experimental procedure for shoulder pain from osteoarthritis.  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 insertion of a Sprint PNS System have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of a Sprint Peripheral Verve Stimulator (PNS) System (64555).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), complete series x-ray (D0210), panoramic x-ray (D0330), and adjunctive pre-diagnostic test (D0431) provided on June 29, 2021.  You asked the Plan to pay for the dental services. You say that the frequency limitation does not state that the limitation applies when you are seeing a new provider. You say that you needed to find a new provider due to your medical issues. You also say that you feel these services should be covered. The Plan denied your request. The Plan says 1 comprehensive oral evaluation is covered every 3 calendar years. The Plan says that 1 panoramic or complete series x-ray is covered every 5 calendar years. The Plan says that the frequency limits for these services have been exceeded. The Plan also says that adjunctive pre-diagnostic test 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 and comprehensive oral evaluation, panoramic x-ray, and complete series x-ray are listed as covered, the frequency limits have been exceeded. The record shows that the Plan paid for a comprehensive oral evaluation and panoramic x-ray that you received on September 25, 2019. Additionally, the adjunctive pre-diagnostic test is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), complete series x-ray (D0210), panoramic x-ray (D0330), and adjunctive pre-diagnostic test (D0431) provided on June 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the deductible for the diagnostic mammogram you had at an outpatient hospital facility on July 20, 2021.  You asked the Plan to waive the deductible for the diagnostic mammogram. You say that this was a regular yearly mammogram, so you shouldn't be charged anything. The Plan denied your request. The Plan says you had a covered screening mammogram on June 18, 2021.  The imaging you had on July 20, 2021 was a diagnostic mammogram to evaluate potential abnormalities in your left breast. The Plan says that you had not met your deductible at the time of these services.  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 basic and advanced diagnostic imaging services.   You already had a covered screening mammogram this year.  This service is a diagnostic mammogram to evaluate something found during your screening mammogram.  The diagnostic mammogram falls within the benefit category of basic and advanced diagnostic imaging services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible which applies to basic and advanced diagnostic imaging services. This cost sharing is a contractual obligation that had not been met at the time the diagnostic mammogram was received on July 20, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the diagnostic mammogram you had at an outpatient hospital facility on July 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the requested prosthetic. .   You asked the Plan to pre-approve a prosthesis. You say that the requested prosthesis and accessories are medically necessary.  The Plan denied your request. The Plan says while a portion of your request was approved, the knee shin system and extension accessories are not covered.   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 requested prothesis and accessories.  Our physician reviewer found that the documentation is insufficient to demonstrate that the knee shin system, fluid stance extension for knee shin system, knee extension assist, microprocessor control feature, and manual lock are 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 the requested prothesis and accessories are not met. Therefore, we decided that the Plan does not have to pre-approve a prosthetic leg to include knee shin system (L5845), fluid stance extension for knee shin system (L5848), knee extension assist (L5850), microprocessor control feature (L5856), and manual lock (L5925).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for tetanus, diphtheria toxoids, and acellular pertussis (TDAP) immunization provided on August 3, 2021.  You asked the Plan to pay for TDAP immunization. You say that you were told this would be covered and to go to a doctor for it rather than a pharmacy. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this immunization is not covered by Medicare Part B.  In the absence of injury or direct exposure to illness, Medicare does not pay for or provide TDAP immunization. The Plan follows the same rules.   Records do not show that you have been injured or directly exposed to any illness related to TDAP immunization. Therefore, we decided that the Plan does not have to pay for tetanus, diphtheria toxoids, and acellular pertussis (TDAP) immunization provided on August 3, 2021.   Benefits for TDAP immunization 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: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for ground transportation services (A0428, A0425) rendered on June 4, 2021.  You asked the Plan to waive the copayment for ground transportation services. You say that you should not be held responsible for the remaining balance on this bill for your transportation. You also say that you were not informed that there would be a charge on your part. The Plan denied your request. The Plan says you were 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 $295 copayment for each Medicare-covered one-way trip via ground ambulance for Ambulance Services.   You have been asked to pay a $295 copayment for each Medicare-covered one-way trip via ground ambulance for ground transportation services. Ground transportation 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 ground transportation services (A0428, A0425) rendered on June 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a adjustable bed from a commercial retailer.   You asked the Plan to pay for an adjustable bed. You say that this bed was medically necessary. The Plan denied your request. The Plan says this type of commercial adjustable bed is not covered by Medicare. The Plan also stated the provider you purchased the bed from is not a Medicare eligible provider.  The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items provided directly by vendor who is not a Medicare eligible provider. The rules say that durable medical equipment must provide a direct medical purpose. Commercial adjustable beds, while they may aid with different types of medical conditions, are not Medicare approved durable medical equipment. You did not purchase this bed from a Medicare eligible equipment provider. Therefore, we decided that the Plan does not have to pay for an adjustable bed purchased from a commercial retailer on April 24, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ambulance transportation services (A0426, A0425) provided on April 5, 2021.  You asked the Plan to pay for the ambulance transportation. You say that this service was necessary and was billed appropriately. The Plan denied your request. The Plan says the enrollee was inpatient status when the ambulance transportation was rendered, and therefore these services are not separately billable from the inpatient hospital care.  The Plan must follow Medicare rules. Medicare rules say that once a beneficiary is admitted to a hospital, it may be necessary to transport the beneficiary to another hospital or other site temporarily for specialized care while the beneficiary maintains inpatient status with the original provider. This movement of the patient is considered "patient transportation" and is covered as an inpatient hospital service.   We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ambulance transportation have not been met. Specifically, the record shows that the enrollee was admitted as inpatient to the origin location provider. The record also shows that the enrollee was moved to another facility in this provider's group while maintaining inpatient status with the original provider. This means that the ambulance service is covered as an inpatient hospital service and is not separately billable. Therefore, we decided that the Plan does not have to pay for the ambulance transportation services (A0426, A0425) provided on April 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a specialist visit provided on June 3, 2021.  You asked the Plan to waive the copayment for a specialist visit. You say that you never went to the physician on this date of service. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 copayment for specialist visits.   The medical records show that you had a specialist visit on June 3, 2021. Therefore, you are responsible to pay the $30 copayment.   You have been asked to pay a $30 copayment for a specialist visit. A specialist visit falls within the doctor 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 specialist visit provided on June 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for DME and related supplies provided on July 22, 2021.  You asked the Plan to waive the coinsurance for DME and related supplies. You say that you returned the supplies and would like to appeal the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for DME and related supplies.   The record shows that you received DME and related supplies on July 22, 2021. The total allowed amount is $185.94 and 20% of that is $37.19.   You have been asked to pay the total coinsurance amount of $37.19 for DME and related supplies. DME and related supplies fall within the 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 DME and related supplies provided on July 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve out of network physician services.   You asked the Plan to pre-approve an out of network provider. You say that you prefer to see the requested provider. The Plan denied your request. The Plan says the requested provider is not in network.  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 provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve out of network physician services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for hospital observation services you received from July 23, 2021, to July 27, 2021.  You asked the Plan to waive the copayment for the hospital observation services. You say that you were sent to the hospital upon medical advice. The Plan denied your request. The Plan says you were charged this copayment correctly. This service was not denied.  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 outpatient hospital observation services.   You have been asked to pay a $200 copayment for the hospital observation 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 copayment for hospital observation services you received from July 23, 2021, to July 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services (87481, 87500, 87556, 87561, 87640, 87641, 87651, 87653, 87798, 87801) provided on December 16, 2020.  You asked the Plan to pay for laboratory services. You say that this is supported in the records. The Plan denied your request. The Plan says this was not billed correctly.  The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS).   We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (87481, 87500, 87556, 87561, 87640, 87641, 87651, 87653, 87798, 87801) provided on December 16, 2020.