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

We decided that the Plan does not have to pay for foot orthotics.
You asked the Plan to pay for foot orthotics. You say that the item was medically necessary. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pay for foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for intravenous infusions provided from December 17, 2020, to December 18, 2020.
You asked the Plan to waive the coinsurance for intravenous infusions. You say that you disagree with the charges and keep receiving charges from the hospital. 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 15% coinsurance for outpatient hospital services. You received intravenous infusions from December 17, 2020, to December 18, 2020, at an outpatient hospital facility. The total allowed amount is $77.36 and 15% of that is $116.61.
You have been asked to pay the total coinsurance amount of $116.61 for intravenous infusions. Intravenous infusions fall within the outpatient hospital services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for intravenous infusions provided from December 17, 2020, to December 18, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the osteogenesis stimulator (E0748), provided on June 29, 2021.
You asked the Plan to waive the coinsurance for the osteogenesis stimulator. You say that the service should be covered. The Plan denied your request. The Plan says the cost share 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 a 15% coinsurance for durable medical equipment (DME) and related supplies. You have been asked to pay a 15% coinsurance for the osteogenesis stimulator. This item 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 the osteogenesis stimulator (E0748), provided on June 29, 2021
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge day management provided on May 6,
2021.
You asked the Plan to pay for the hospital discharge day management. You say that the physician provided the
hospital discharge service, and the patient was discharged into hospice care. You say that according to Plan
policy the physician provided a payable service, and the claim should be processed and paid. The Plan denied
your request. The Plan says Original Medicare is responsible for payment.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services.
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for the hospital discharge day management provided on May 6,
2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance service provided on May 20, 2021.
You asked the Plan to waive the copayment for the ambulance service. You say that the service should be covered. The Plan denied your request. The Plan says the cost share 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 a $275 copayment for ambulance services. You have been asked to pay a $275 copayment for the ambulance service. This service falls within the ambulance services benefit category. You have been asked to pay $226.97 out of the $275 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 copayment for the ambulance service provided on May 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an auricular nerve stimulator.
You asked the Plan to pre-approve an auricular nerve stimulator. You say that this request is medically reasonable and necessary. The Plan denied your request. The Plan says this item is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. Medicare rules say that an auricular nerve stimulator is not covered by Medicare. We looked at the file and Medicare rules. In this case, the requested auricular nerve stimulator is not covered according to Medicare rules. Based on this information, we decided that Medicare rules for coverage of an auricular nerve stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve an auricular nerve stimulator.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lipectomy (liposuction) and a rhytidectomy (facelift).
You asked the Plan to pre-approve a lipectomy (liposuction) and a rhytidectomy (facelift). The Plan denied
your request. The Plan says the requested procedures seem to be cosmetic surgery (procedures that intend
solely to refine or reshape structures or surfaces that are not functionally impaired) rather than Gender
Affirming. The Plan excludes coverage for any surgeries, services or procedures that are purely cosmetic when
performed solely to enhance appearance, but not to medically treat the underlying gender dysphoria.
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 lipectomy (liposuction) and a
rhytidectomy (facelift). Our reviewer says that the requested lipectomy (liposuction) and rhytidectomy
(facelift) are not considered medically reasonable and necessary in this case. Our physician reviewer found the
record indicates that you have gender dysphoria. The record provided is insufficient to establish the medical
necessity and reasonableness of the requested services at this time. The record provided does not establish the
medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of
the coverage criteria are not satisfied. The requested service is not recommended.
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 lipectomy (liposuction) and a rhytidectomy (facelift) have not been met.
Therefore, we decided that the Plan does not have to pre-approve a lipectomy (liposuction) and a rhytidectomy
(facelift).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services provided to the enrollee on August 3, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the records indicate a National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists between 71046 and 71045.
This PTP edit has a modifier indicator of 1, which indicates modifiers associated with NCCI are allowed, however, an appropriate NCCI modifier was not billed with this PTP code edit.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes and when required the appropriate modifiers. In this case, this claim cannot be paid as billed due to the omission of the required modifier. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for imaging services provided to the enrollee on August 3, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (81479) provided on May 20, 2021.
You asked the Plan to pay for laboratory services. You say that this is a covered service. 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 (81479) provided on May 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the dual-energy bone density study provided on July 23, 2021.
You asked the Plan to pay for the testing services. You say that the enrollee had multiple exams on this date of service. The Plan denied your request. The Plan says the rules for payment have not been met.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. In this case, the MUE for CPT code 77080 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the dual-energy bone density study provided on July 23, 2021
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation services (A0428, A0425) provided on July 31, 2021.
You asked the Plan to waive the copayment for the ambulance transportation. You say that you were transported to the hospital on an earlier date and were told that you could pay your copayment for that service in a payment plan and have your costs reduced. You do not understand why the same is not being done for this second ambulance transportation claim with a different company. You did not have a say in how these services were provided, and you live on a fixed income. The Plan denied your request. The Plan says this claim was processed correctly, and your copayment was assessed in accordance with your contract. Ambulance services require a $290 copayment. However, the allowed cost (the Plan's discounted rate) for these services was less than this amount in this case, so you are only responsible for $265.10.
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 $290 copayment for ground ambulance transportation.
You have been asked to pay $265.10 for the ambulance transportation. 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 ambulance transportation services (A0428, A0425) provided on July 31, 2021.
Please note: The ambulance provider in this case is not contracted with the Plan. Ambulance providers are rarely contracted with insurance companies, because it is impossible to determine who will respond to any particular call. If you have a grievance with the ambulance provider regarding payment plans or a potential change in agreement regarding payment, you may wish to contact the provider directly.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the prophylaxis (D1110) provided on April 30, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay more for the prophylaxis. You say that you were advised by the Plan and the provider's office that this treating provider accepted your insurance. The Plan denied your request. The Plan says this service was rendered by an OON provider and the Plan paid the allowed amount. The Plan also says that any remaining balance for this service is your responsibility.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, you are responsible for the difference between the billed amount and allowed amount for covered dental services received OON. The record shows that there were no contacts made to the Plan prior to this date of service, and the provider verified that there are no in-network providers at their practice. Therefore, we decided that the Plan does not have to pay more for the prophylaxis (D1110) provided on April 30, 2021 by an out-of-network (OON) provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the automatic external defibrillator (K0606), provided on September 3, 2021, through October 2, 2021.
You asked the Plan to waive the coinsurance for the automatic external defibrillator. You say that the item should be covered. The Plan denied your request. The Plan says the cost share 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 a 20% coinsurance for durable medical equipment (DME) and related supplies. You have been asked to pay a 20% coinsurance for the automatic external defibrillator. the automatic external defibrillator 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 the automatic external defibrillator (K0606), provided on September 3, 2021, through October 2, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for debridement provided from May 6, 2021, to June 24, 2021.
You asked the Plan to waive the copayments for debridement. You say that you did not receive any procedures during the visits and the doctor only looked at the wound to make sure there was no infection. 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 $295 copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers. The medical records show that you received debridement at an outpatient hospital facility from May 6, 2021, to June 24, 2021, for a total of 7 visits. Debridement is considered an outpatient surgical procedure. Therefore, you are responsible to pay a $295 copayment per each visit.
The total amount you owe is: $295 (copayment) x 7 (debridement services) = $2,065. You have been asked to pay the total copayment amount of $2,065 for debridement. Debridement falls within the outpatient surgery and other medical 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 copayments for debridement provided from May 6, 2021, to June 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 1 standard power operated vehicle for the enrollee.
You asked the Plan to pre-approve the vehicle. You say that this is medically necessary. The Plan denied your request. The Plan says there are no clinical notes which show that a scooter is indicated.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 vehicle. Our reviewer says that the requested vehicle is not medically reasonable or necessary. Our physician reviewer found there is no documentation that this enrollee has a personal mobility deficit that impairs participation in mobility related activities of daily living such as toileting, feeding, grooming and bathing in customary locations within the home. Based on the medical records provided, there is no documentation that the enrollee's mobility deficit
cannot be helped by the use of a walker, cane or manual wheelchair. There is no documentation that the enrollee could safely operate a power mobility device. 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 vehicle have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 1 standard power operated vehicle for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound exam of the abdominal back wall (76770) and the ultrasound of the pelvis (76856) provided on May 21, 2021.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has 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 a $85
copayment for each Medicare-covered radiological diagnostic service, not including x-rays performed in a
physician's office or at a free-standing facility (such as a radiology center or medical clinic).
You have been asked to pay a $85 ($77.39 + $7.61) copayment for the Medicare-covered radiological
diagnostic services provided. The allowed amount for code 76770 billed was $77.39. You are responsible for a
copayment of $85.00 for each radiological diagnostic service. Since the allowed amount is lower than your
copayment amount of $85.00, you were only assessed a copayment of $77.39. Additionally, the allowed
amount for code 76856 billed was $48.54 in which the Plan paid $40.93; subsequently leaving a balance of
$7.61 that was applied to the copayment liability for a total of $85. 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 ultrasound exam of the abdominal back wall (76770) and the ultrasound of the pelvis
(76856) provided on May 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve special eyeglasses that will cost $1,021.
You asked the Plan to pre-approve eyeglasses. You say that you feel the Plan should cover these glasses. The
Plan denied your request. The Plan says they have agreed to cover up to the Plan's benefit allowance of $200
for the eyeglasses, but you will be responsible for the remaining cost.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan covers up to $200 for routine eyewear every year.
We looked at the file and the Plan's rules. The Plan has pre-approved the requested glasses up to the $200
benefit limit, but the remaining cost exceeds this allowance. Therefore, we decided that the Plan does not have
to pre-approve the full cost of the requested special eyeglasses that will cost $1,021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Cxbladder testing rendered on March 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 testing is not covered.
The Plan must follow Medicare rules. The rules say that the Cxbladder testing is non-covered. We looked at the file and Medicare rules. The test at issue is Cxbladder. This test is not covered by Medicare. Therefore, we decided that the Plan does not have to pay for the Cxbladder testing rendered on March 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided the Plan does not have to pay for a continuous passive motion device provided on March 16, 2021.
You asked the Plan to pay for this device. You say that this claim should be paid. The Plan denied your request. The Plan says the records do not show the enrollee had knee surgery.
The Plan must follow Medicare rules. The rules say that coverage for knee stretching devices is limited enrollees who had knee surgery. The records provided do not show the enrollee had knee surgery. Medicare coverage criteria are not met. Therefore, we decided that the Plan does not have to pay for a continuous passive motion device provided to the enrollee on March 16, 2021.