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

 We decided that the Plan does not have to waive the coinsurance for oxygen equipment (E1390, E0431) provided on September 23, 2021.  You asked the Plan to waive the coinsurance for the oxygen equipment. You say that the item should be covered. The Plan denied your request. The Plan says the coinsurance applied correctly based on the item 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 20% coinsurance for Durable medical equipment (DME) and related supplies.     You have been asked to pay a 20% coinsurance for the oxygen equipment (total allowed is $158.51 x 20% = $31.70). Oxygen equipment 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 oxygen equipment (E1390, E0431) provided on September 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180), and prophylaxis (D1110) provided on August 9, 2021.  You asked the Plan to pay for the dental services. You say that the frequency limit has not been exceeded.  You say that the treatment code was not applied correctly. You also say that the treatment you received in 2020 was a periodic oral exam. The Plan denied your request. The Plan says 1 comprehensive periodontal evaluation is covered every 3 calendar years. The Plan also says that the frequency limit has been exceeded.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage and comprehensive periodontal evaluation is listed as covered, the frequency limit has been exceeded.  The record shows that the Plan paid for a comprehensive periodontal evaluation that you received on August 7, 2020. Therefore, we decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180), and prophylaxis (D1110) provided on August 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for the office visits (99214) provided on September 9, 2021 and September 15, 2021.  You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to 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 $40 for each covered visit or consultation in an outpatient location with a specialist.     You have been asked to pay $80 ($40 copayment x 2) for the specialist office visits provided. 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 copayments for the office visits (99214) provided on September 9, 2021 and September 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a positioning cushion (E0190)  You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee has similar equipment in good condition.  The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and 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 the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the medical records provided, there is no documentation that the previously approved positioning cushion from 2020 has been lost, stolen or irreparably damaged such that Medicare criteria for approval of a new positioning cushion are met.  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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve a positioning cushion (E0190)
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for an outpatient diagnostic test provided on August 20, 2021.  You asked the Plan to waive the coinsurance for the outpatient diagnostic test. You say that the services should be covered. The Plan denied your request. The Plan says the coinsurance 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 15% coinsurance for Outpatient diagnostic tests and therapeutic services and supplies.        You have been asked to pay a 15% coinsurance for the outpatient diagnostic test ($6.21 copayment). 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 an outpatient diagnostic test provided on August 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for oxygen equipment (E1390, E0431) provided on August 23, 2021.  You asked the Plan to waive the coinsurance for the oxygen equipment. You say that the item should be covered The Plan denied your request. The Plan says the coinsurance applied correctly based on the item 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 20% coinsurance for Durable medical equipment (DME) and related supplies.     You have been asked to pay a 20% coinsurance for oxygen equipment (total allowed is $158.51 x 20% = $31.70). Oxygen equipment 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 oxygen equipment (E1390, E0431) provided on August 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve complete upper and lower dentures (D5120, D5110).  You asked the Plan to pre-approve dentures. You say that these services are necessary. The Plan denied your request. The Plan says you previously received complete upper and lower dentures in July 2018. These services were covered by the Plan at that time.  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 dentures. Authorizations for removable dentures will not meet criteria if there is a pre-existing prosthesis which is not at least five years old and unserviceable.  Though the Plan offers a dental benefit in excess of Medicare coverage, the dentures are requested in a frequency that exceeds what is covered under this benefit. Documentation shows that the Plan paid for upper and lower dentures for you less than five years ago. Therefore, we decided that the Plan does not have to pre-approve complete upper and lower dentures (D5120, D5110).
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an Euflexxa injection (J7323) provided on August 30, 2021.  You asked the Plan to waive the copayment for the Euflexxa injection. You say that the services should be covered as you were unaware of the copayment. 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 20% coinsurance for Medicare Part B prescription drugs.    You have been asked to pay a 20% coinsurance for the Euflexxa injection (allowed amount is $2,043.65 x 20% = $408.73). Euflexxa injections fall within the Medicare Part B prescription drugs 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 Euflexxa injection (J7323) provided on August 30, 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 denial of this admission will seriously jeopardize the enrollee's life, health, and ability to regain function. The Plan denied your request. The Plan says the member does not meet the criteria for an IRF.  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 was admitted for surgical repair of an ankle fracture after a fall. The enrollee's medical problems are stable and there are no complex nursing or rehabilitation needs.  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: Unfavorable

 We decided that the Plan does not have to waive the copayment for a specialist office visit provided on September 21, 2021.  You asked the Plan to waive the copayment for the specialist office visit. You say that the services should be covered, and you don't agree with the Plans decision. 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 $35 copayment for Physician/Practitioner services, including doctor's office visits.     You have been asked to pay a $35 copayment for a specialist office visit. The record indicates that the provider you saw is an otolaryngology specialist. Specialist office visits fall within the Physician/Practitioner services, including doctor's office visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a specialist office visit provided on September 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a custom abutment (D6057) and abutment supported crown (D6059) for tooth # 13.  You asked the Plan to pre-approve the dental services. You say that you would not be able to eat correctly without these services. The Plan denied your request. The Plan says custom abutment and abutment supported crown are not listed as covered 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 requested services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a custom abutment (D6057) and abutment supported crown (D6059) for tooth # 13.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve pneumatic compression devices (E0652, E0668).  You asked the Plan to pre-approve pneumatic compression devices. You say that the requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for pneumatic compression devices have not been met.  The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.  We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. The item coded E0668 is not separately payable when the base item is not covered. Therefore, we decided that the Plan does not have to pre-approve pneumatic compression devices (E0652, E0668).
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the removal of a recurring cataract provided on October 19, 2021.  You asked the Plan to waive the copayment for the removal of a recurring cataract. You say that you feel that this should have been done during the initial surgery and you should not owe another copayment. 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 $250 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers.  The record shows that you received the removal of a recurring cataract provided at an outpatient hospital facility on October 19, 2021. The removal of a recurring cataract is considered an outpatient surgical procedure. Therefore, you are responsible to pay the allowed amount of $213.86, which is less than the $250 copayment.   You have been asked to pay $213.86 for the removal of a recurring cataract. The removal of a recurring cataract falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 the removal of a recurring cataract provided on October 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213) to be provided by a participating provider.  You asked the Plan to pre-approve a maxillary partial denture. You say that you lost your partials, and you are now in a lot of pain. The Plan denied your request. The Plan says the benefit limit for D5213 has already been exhausted.  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 one set of maxillary partial denture every five years.   We looked the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a maxillary partial denture have already been exhausted. Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture (D5213) to be provided by
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for dispensing new spectacle lenses in a patient-supplied frame (S0595) provided on July 30, 2021.  You asked the Plan to pay for dispensing of new lenses into patient supplied frames. You say that no one informed you that this service would not be covered, and you would not have brought your own frames if the Plan's provider had better options available. The Plan denied your request. The Plan says this service is not covered by Medicare or your supplemental vision benefit.  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.  While the Plan offers a vision benefit in excess of Medicare coverage, the requested service is not among those listed as covered under this benefit. Based on this information, we decided that the Plan's rules for coverage of dispensing of new lenses into patient supplied frames have not been met. Therefore, we decided that the Plan does not have to pay for dispensing new spectacle lenses in a patient-supplied frame (S0595) provided on July 30, 2021.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a home personal sitter.  You asked the Plan to pre-approve a home personal sitter. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit of Medicare or the Plan.  The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from trained medical or paramedical staff, is not covered.   We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a home personal sitter have not been met. Specifically, we find that the services at issue in this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve a home personal sitter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve removal of lateral exostosis (D7471).  You asked the Plan to pre-approve the dental service. You say that you need this service done so that you can get dentures. The Plan denied your request. The Plan says removal of lateral exostosis is not listed as a covered service.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested removal of lateral exostosis is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve removal of lateral exostosis (D7471).
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the testing (81455) provided on June 17, 2021.  You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered service.  The Plan must follow Medicare rules. Medicare rules say that targeted genomic sequence analysis panel, hematolymphoid neoplasm, DNA analysis, 5-50 genes (CPT 81450) is a useful representation of the aggregate of these gene tests, and may be used as long as the panel contains, at a minimum, 5 or more gene tests for molecular biomarkers determined to meet Medicare coverage criteria.      We looked at the file and Medicare rules. The panel in this case tested more than 50 genes. Per LCA A56793, testing of more than 50 genes is not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for the testing (81455) provided on June 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the office visit rendered on September 8, 2021.  You asked the Plan to waive the coinsurance for these services. You say that this was the only hospital that could perform the surgery you needed. The Plan denied your request. The Plan says the coinsurance was applied 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 50% of the total allowed amount, per provider, per day for each out-of-network Medicare-covered specialist office visit.   Review if the file shows that you received specialist services from an out-of-network provider on September 8, 2021. You have been asked to pay 50% of the total allowed amount for these services. These services fall within the each out-of-network Medicare-covered specialist office visit 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 the office visit rendered on September 8, 2021.