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

We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2311, E2313, E2377) for the enrollee.
You asked the Plan to pre-approve the additional accessories. You say that this is medically necessary. The Plan denied your request. The Plan says upper limb strength and function are therefore adequate for the enrollee to be able to control the power options using their own switches which are included in the allowance of these power options.
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 additional accessories. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee does not require non-proportional input devices (e.g., sip and puff, head array, etc.). The enrollee does not require a separate display (i.e., for alternate control devices), other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. The enrollee has 3 power options of tilt, recline, and power elevating leg rests but the enrollee does not need to control the power options through a joystick. The enrollee's upper extremity strength and function including independence in grooming and meal prep support that the enrollee can control any power options through their own switches. 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 additional accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2311, E2313, E2377) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services provided from April 22, 2021, to April 30, 2021.

You asked the Plan to waive the copayment for the inpatient hospital services. You say that you are on social security and cannot afford the charges. The Plan denied your request. The Plan says the enrollee was 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). The enrollee's contract with the Plan clearly says that enrollees must pay $250 per day for days 1-7 and $0 per day after day 7 for each inpatient stay. The record shows that the enrollee was in the hospital from April 22, 2021, to April 30, 2021.

Therefore, the enrollee had been asked to pay $250 per day for the first 7 days of inpatient hospital services. The total for the stay is $1750 ($250 copayment x 7 days = $1750). The inpatient hospital services fall within the Inpatient Hospital Care benefit category. This means that the enrollee had been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital services provided from April 22, 2021, to April 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on August 27, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the office visit. You say that the provider is in-network, and a prior authorization was not needed. 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 record shows the provider is out-of-network. Therefore, we decided that the Plan does not have to pay for the office visit provided on August 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 hearing aids provided on August 31, 2021.
You asked the Plan to pay for the hearing aids. You say that you were under the impression that you had hearing aid coverage with out-of-network providers. The Plan denied your request. The Plan says you did not contact the Plan's hearing aid vendor.
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.
We looked at the file and the Plan's rules. The file shows that the hearing aids were not purchased from the Plan's hearing aid vendor. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids provided on August 31, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy services (97116, 97110, 97162, 97140) rendered from December 14, 2020, to December 29, 2020.
You asked the Plan to waive the copayment for physical therapy services. You say that you were not being billed your copayment and you would not have had all your sessions if you had known the charges beforehand. You also say you do not believe you owe the amount because you were not aware of your copayment per session. 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 $30 copayment for each Medicare-covered physical therapy or speech therapy visit.
You have been asked to pay a $30 copayment for each physical therapy service. Physical therapy 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 physical therapy services (97116, 97110, 97162, 97140) rendered from December 14, 2020, to December 29, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the refractive keratoplasty provided on March 20, 2019.

You asked the Plan to pay for the refractive keratoplasty. The Plan denied your request. The Plan says the cataract surgery processed with no member liability. The unlisted eye procedure remains denied.

The Plan must follow Medicare rules. Medicare rules say that the correction of common refractive errors by eyeglasses, contact lenses or other prosthetic devices is specifically excluded from coverage.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the refractive keratoplasty have not been met. Therefore, we decided that the Plan does not have to pay for the refractive keratoplasty provided on March 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on April
29, 2021.
You asked the Plan to waive the copayment for the specialist office visit. You say that you were not advised
there would be a charge. You say you only requested an annual hearing exam. The Plan denied your request.
The Plan says you have been asked to pay 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 $50
copayment for services obtained from a specialist or under certain circumstances, treatment by a nurse
practitioner or physician's assistant or other non-physician health care professionals in a specialist's office.
You have been asked to pay a $50 copayment for the specialist office visit. The specialist office visit falls
within the "Physician/Practitioner Services, Including Doctor's Office Visits" benefit category. The record
shows an ear wax removal service was performed in addition to the annual hearing exam.
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 specialist office visit provided on April 29, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on April 5, 2021.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says these services are
not payable.
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate.
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for
the lab services provided on April 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a specialist office visit (99212) provided on June 15, 2021,
by an out-of-network (OON) provider.
You asked the Plan to pay for a specialist office visit. You say that you are appealing and have submitted
supporting documentation. The Plan denied your request. The Plan says this provider is not a network provider
with the Plan and the services were not referred by a network provider or rendered in an in-network facility.
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 a specialist office visit (99212) provided on June
15, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit provided on August 2, 2021.
You asked the Plan to pay for the visit. The Plan denied your request. The Plan says the services were billed incorrectly
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 99214 is "Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 30-39 minutes of total time is spent on the date of the encounter". We find that CPT code 99214 is not supported in the medical record. Specifically, the records show that the services in question were provided in the emergency department. It is inappropriate to bill code 99214 for an emergency department visit. Based on this information, we decided that Medicare rules for coverage of the
visit have not been met. Therefore, we decided that the Plan does not have to pay for the emergency department
visit provided on August 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a telephone visit (99441) provided on September 16, 2021,
by an out-of-network (OON) provider.
You asked the Plan to pay for a telephone visit. You say that it was impossible to obtain authorization, due to
the patient giving you the incorrect insurance information by stating she had Medicare and not a Medicare
advantage plan. You also say that the provider is not responsible to request authorization for a Medicare patient
to whom he renders services. The Plan denied your request. The Plan says this provider is not a network
provider with the Plan and the services were not referred by a network provider or rendered in a participating
facility. 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 a telephone visit (99441) provided on September
16, 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 magnetic resonance imaging (MRI) of the
lumbar spine provided on November 18, 2021.
You asked the Plan to waive the copayment for the MRI. You say that you had this procedure done a year ago
and only had to pay $60. The Plan denied your request. The Plan says you have been charged the correct cost
sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300
copayment for each diagnostic imaging service, including MRI's.
You have been asked to pay $219.97, which is less than the $300 copayment for the MRI. The MRI 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 magnetic resonance imaging (MRI) of the lumbar spine
provided on November 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for supplies provided to the enrollee on February 17, 2021.
You asked the Plan to pay for the supplies. You say that this should be paid for. The Plan denied your request.
The Plan says the billed items on the claim were denied because the claim history indicates inpatient status on
this date of service.
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 the denied codes is:
HCPCS A4450:
Tape, non-waterproof, per 18 square inches
HCPCS A6252:
Gauze, impregnated with other than water, normal saline, or hydrogel, sterile, pad size 16 sq. in. or less,
without adhesive border, each dressing
HCPCS A6222:
Specialty absorptive dressing, wound cover, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq.
in., without adhesive border, each dressing
HCPCS A6446:
Conforming bandage, non-elastic, knitted/woven, sterile, width greater than or equal to three inches and less
than five inches, per yard
We find that the denied codes are not supported in the medical record. Specifically, it is improper to bill these
codes separately in this case. A4450 and A6446 have a status code of "X" which means that it is statutorily
excluded. The other codes have a status indicator of "P" which means they are bundled/excluded codes, and
cannot be paid separately. Based on this information, we decided that Medicare rules for coverage of the
supplies have not been met. Therefore, we decided that the Plan does not have to pay for supplies provided to
the enrollee on February 17, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on April 12, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services were not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of
service (POS) code.
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory
services rendered on April 12, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on
September 27, 2021.
You asked the Plan to waive the copayment for the ER visit. You say that you left the ER before seeing a
provider. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90
copayment for each emergency room visit.
The record shows that the ER staff took vital signs and did lab work while you were in the waiting room. Since
these services were provided, you have been asked to pay a $90 copayment for the ER visit. The ER visit falls
within the Emergency 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 waive the copayment for an
emergency room (ER) visit provided on September 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220) and additional
intraoral periapical x-ray (D0230) provided on October 19, 2021, by an OON provider.
You asked the Plan to pay for the intraoral x-rays. You say that you would like these x-rays to be reconsidered
for coverage. The Plan denied your request. The Plan says these services are not covered by the Plan.
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. The only type of x-rays that are covered under the Plan are horizontal
bitewing x-rays. Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray
(D0220) and additional intraoral periapical x-ray (D0230) provided on October 19, 2021, by an OON provider.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pay for the rhythm electrocardiogram (ECG) report rendered on January 30,
2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says that procedure code 93042 is not separately payable.
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 states that a procedure to procedure (PTP) edit exists between code
93042 (rhythm ECG report) and 99291 (critical care services); however, there are no National Correct Coding
Initiatives (NCCI) edits for these codes. The Plan has not provided any documentation to support that the code
is not payable as billed. Therefore, we decided that the Plan has to pay for the rhythm electrocardiogram (ECG)
report rendered on January 30, 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on February 25, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on February 25, 2021.