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

 We decided that the Plan does not have to pay for the knee orthosis (L1833) provided April 20, 2021 You asked the Plan to pay for the orthosis. You say that please reconsider for medical necessity. the L1833 knee brace was prescribed by the physician to support the enrollee's knee following knee replacement surgery. The Plan denied your request. The Plan says the claim was not billed with an appropriate modifier.  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 L1833-LT is nee orthosis (KO), adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support, prefabricated, off-the-shelf.  We find that CPT code L1833-LT is not supported in the medical record. Specifically, the claim was not billed with an appropriate modifier KX for any item to be covered by Medicare. Based on this information, we decided that Medicare rules for coverage of the orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1833) provided April 20, 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 October 14, 2021.  You asked the Plan to waive the copayment for the ER visit. You say that the provider did not help your condition and you feel that you should not be responsible for the copayment. 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 $50 copayment for each emergency room visit.   You have been asked to pay a $50 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 October 14, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for chemotherapeutic treatment provided on July 13 to July 29, 2021.  You asked the Plan to waive the coinsurance for chemotherapeutic treatment. You say that you are unable to pay this amount. The Plan denied your request. The Plan says the correct coinsurance was applied.  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 Medicare Part B chemotherapy/radiation drugs and other Medicare Part B drugs.   You have been asked to pay $3,387.42, or less than 20% of the Medicare-allowed charges of $20,427.66, for chemotherapeutic treatment. Chemotherapeutic treatment falls within the "Medicare Part B prescription drugs" benefit category. This means that you have been asked to pay less than or equal to 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 chemotherapeutic treatment provided on July 13 to July 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the muscle, myocutaneous, or fasciocutaneous flap procedure (15733) rendered by the out-of-network (OON) provider on October 13, 2020.  You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.  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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the muscle, myocutaneous, or fasciocutaneous flap procedure (15733) rendered by the out-of-network (OON) provider on October 13, 2020.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on March 1, 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 are not covered.  The Plan must follow Medicare rules. The rules say that genetic testing procedures submitted under CPT code 81540 will be denied automatically as not medically necessary.  We looked at the file and Medicare rules. The file shows that the services were billed under code 81540. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on March 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a primary care physician (PCP) office visit provided on September 3, 2021.  You asked the Plan to waive the copayment for the PCP office visit. You say that you were there for a physical and it should be fully covered. 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 $0 copayment for an annual physical. If you receive services that address a medical condition during the same office visit, additional cost sharing may apply.  Your contract with the Plan clearly says that you must pay a $10 copayment for each consultation with your PCP.   The file shows that during your visit, you had discussed possible knee surgery and hot flashes. These additional issues go beyond the scope of an annual physical. Therefore, you have been asked to pay a $10 copayment for the PCP office visit. The PCP office visit falls 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 primary care physician (PCP) office visit provided on September 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve additional features for a leg prosthetic (L5920, L5968, L5972)  

You asked the Plan to pre-approve the additional features. You say that this is medically necessary. The Plan denied your request. The Plan says the requested items are not medically necessary.  

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 features. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested items exceed the enrollee's medical needs and are not medically necessary. The documentation does not support that the enrollee is a K2 ambulator, or expected to be a K2 ambulator. The enrollee was recently approved for a power mobility device to perform mobility related activities of daily living in the home. The L5920 is not medically necessary as the approved prosthesis is a non-alignable system, therefore it exceeds medical need.  

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 features have not been met. Therefore, we decided that the Plan does not have to pre-approve additional features for a leg prosthetic (L5920, L5968, L5972)
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the oral exam (D0120) provided on July 14, 2021.  You asked the Plan to pay for the oral exam. You say that your wife was reimbursed for the same services. The Plan denied your request. The Plan says the provider in this case is not eligible for payment.  Medicare generally does not cover dental services. The rules say that no payment is made to any business or facility, e.g., a hospital, that submits claims for payment of items or services provided, ordered, prescribed, or referred by an excluded party.  Though the Plan offers a dental benefit in excess of Medicare coverage, the provider in this case is not eligible to accept payment. Therefore, we decided that the Plan does not have to pay for the oral exam (D0120) provided on July 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the deep sedation/general anesthesia - first 15 minutes (D9222), deep sedation/general anesthesia - each subsequent 15-minute increment (D9223), and extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210) provided August 13, 2021.  You asked the Plan to pay for the deep sedation and tooth extraction. You say that your Evidence of Coverage does not include the exclusion about not covering services from opt-out providers. The Plan denied your request. The Plan says these services are not covered because they were rendered by a provider who has opted out of Medicare.  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 the deep sedation and tooth extraction when you see any provider who accepts Medicare patients in the United States and has not opted out of Original Medicare.  We looked at the file and Medicare rules. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Based on this information, we decided that the Plan's rules for coverage of the deep sedation and tooth extraction have not been met. Therefore, we decided that the Plan does not have to pay for the deep sedation/general anesthesia - first 15 minutes (D9222), deep sedation/general anesthesia - each subsequent 15-minute increment (D9223), and extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210) provided August 13, 2021.   Your complaint about feeling your Evidence of Coverage does not adequately provide information about exclusions from your supplemental benefits is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to waive the cost-sharing for an office visit provided on June 2, 2021.  You asked the Plan to waive the cost-sharing for an office visit. You say that you only saw your physician for 10 minutes. You say that you are disputing the billing for a 30-to-39-minute visit. The Plan denied your request. The Plan says that the cost-sharing applied was correct.  The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.  The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not provide medical records showing the length of your office visit. Therefore, we decided that the Plan has to waive the cost-sharing for an office visit provided on June 2, 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: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve additional physical therapy (PT) visits.  

You asked the Plan to pre-approve additional PT visits. You say that additional PT is medically necessary. The Plan denied your request. The Plan says additional PT is not medically necessary.  

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.    

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 additional PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that you have previously been treated with outpatient therapies and should be independent with a home exercise program. There is no documentation of a recent injury or decline in function. The additional therapy services are not an appropriate duration and frequency for treatment of your medical condition and therefore are not medically 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 additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve additional PT visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for an ankle orthosis (L1902) provided on June 2, 2021.  You asked the Plan to waive the coinsurance for an ankle orthosis. You say that you feel you do not have to pay this, and you want the Plan to pay the coinsurance. You also say you are on a fixed income and cannot afford it. 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 20% coinsurance for Medicare-covered items for durable medical equipment (DME) and related supplies.    You have been asked to pay $14.99 in coinsurance, which is 20% of the allowed amount for an ankle orthosis ($74.93 allowed amount x 20% coinsurance = $14.99). An ankle orthosis 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 an ankle orthosis (L1902) provided on June 2, 2021.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an emergency room visit provided from October 21, 2021, to October 23, 2021.  You asked the Plan to waive the copayment for the emergency room visit. You say that the services should be covered as you were initially admitted. 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 $90 copayment for Emergency care.    You have been asked to pay a $90 copayment for an emergency room visit. The record indicates that you were in observation status and were not admitted. 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 visit provided from October 21, 2021, to October 23, 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 for the enrollee.  You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level.  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.   The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient's medical conditions have improved,/ and he is reported to be stable on outpatient medications with no issues that require a physician's evaluation three or more times per week. The patient does require physical therapy and occupational therapy services but based on the medical records provided the patient does not require an intensive inpatient rehabilitation therapy program. There is no documentation that the patient requires the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care.  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 for the enrollee.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an esophagogastroduodenoscopy (EGD) with biopsy performed on July 21, 2021.  You asked the Plan to waive the copayment for the EGD. You say that you do not understand why a colonoscopy is free but this procedure has a $295 charge. 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 $295 copayment for surgery or other services provided at an outpatient hospital.   You have been asked to pay a $295 copayment for the EGD. The EGD 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 an esophagogastroduodenoscopy (EGD) with biopsy performed on July 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for implant maintenance (D6080), and an unspecified fixed prosthodontic procedure (D6999) provided by an out-of-network provider on September 9, 2021.  You asked the Plan to pay for implant maintenance and an unspecified fixed prosthodontic procedure. You say that you have had these services covered in the past. You say that you would like the Plan to pay for this. The Plan denied your request. The Plan says the rendered dental services are not covered dental benefits.  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. Therefore, we decided that the Plan does not have to pay for implant maintenance (D6080), and an unspecified fixed prosthodontic procedure (D6999) provided by an out-of-network provider on September 9, 2021.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for an emergency department visit provided on  September 17, 2021.  You asked the Plan to pay for the emergency department visit. You say that the patient was not enrollee in hospice on this date of service. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged. Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.  The enrollee ended Medicare hospice benefits on September 10, 2021. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for an emergency department visit provided on September 17, 2021.