Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided on July 23, 2021.  You asked the Plan to waive the copayment for the inpatient hospital care. 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $250 copayment per admission for each medically necessary inpatient stay for inpatient hospital care.   The enrollee has been asked to pay a $250 copayment per admission for each medically necessary inpatient stay for the inpatient hospital care. This service falls within the inpatient hospital care benefit category. This means that the enrollee has 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 the inpatient hospital care provided on July 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ultralight manual wheelchair and related accessories.

You asked the Plan to pre-approve an ultralight manual wheelchair and related accessories. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested item is not medically necessary.

The Plan follows Medicare rules. Medicare rules say that an ultralight wheelchair is only covered for certain indications.

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 an ultralight manual wheelchair and related accessories. Our reviewer says that the documentation does not support that the requested ultralight wheelchair is medically reasonable or necessary. Our physician reviewer found the enrollee has a past medical history of cerebral palsy and bilateral lower extremity amputations. Records do not include a signed letter of medical necessity from the enrollee's treating provider. Records do not clarify that the enrollee has the cognitive ability and upper extremity strength and function to adequately and safely use the requested wheelchair. Therefore, the enrollee does not meet criteria for the requested item. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an ultralight manual wheelchair and related accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve an ultralight manual wheelchair and related accessories.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the power wheelchair repairs (K0739), replacement of remote joystick (E2374), and electronic connection (E2310).
You asked the Plan to pre-approve the durable medical equipment services. You say that these replacement services are necessary. The Plan denied your request. The Plan says the requested repair features are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that an electrical connection described by code E2310 whose sole function is the connection for a power seat elevation feature, it will be denied as non-covered. The rules also say that E237 is the correct replacement code for E2373. We looked at the file and Medicare rules. In this case, no power options have been approved for the wheelchair in question. Therefore, the requested electronic connection is not medically necessary. Furthermore, there is no evidence that the wheelchair was initially approved for the joystick described by code E2373.
Therefore, it is not reasonable to replace this joystick. These repair services are not medically reasonable and necessary. Based on this information, we decided that Medicare rules for coverage of the durable medical equipment services have not been met. Therefore, we decided that the Plan does not have to pre-approve the power wheelchair repairs (K0739), replacement of remote joystick (E2374), and electronic connection (E2310).
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for CxBladder testing (0012M) provided on July 2, 2021.  You asked the Plan to pay for CxBladder testing. You say that evidence supports the use of this testing as a medically necessary diagnostic service. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this testing is not covered by Medicare.  The Plan must follow Medicare rules. Medicare rules say that CxBladder test code 0012M is not covered by Medicare.   We looked at the file and Medicare rules. This test is not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of CxBladder testing have not been met. Therefore, we decided that the Plan does not have to pay for CxBladder testing (0012M) provided on July 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a specialist visit provided on June 8, 2021.  You asked the Plan to waive the copayment for a specialist visit. You say that you were told that the provider was in-network. 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 $35 copayment for in-network specialist visits and a $55 copayment for out-of-network specialist visits.  The record shows that you received specialist services from an out-of-network provider on June 8, 2021. Therefore, you are responsible to pay the $55 copayment.   You have been asked to pay a $55 copayment for a specialist visit. A specialist 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 specialist visit provided on June 8, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for the physical therapy services provided on August 3, 2021, and August 16, 2021.  You asked the Plan to waive the copayments for physical therapy. You say that you have already paid these copayments and feel these bills should be waived. The Plan denied your request. The Plan says this claim was processed in accordance with your contract. If you have already paid this amount for these services and the provider is still trying to bill you, proof of payment may be submitted to the provider or the Plan.  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 copayment for each Medicare-covered physical therapy visit.    You have been asked to pay a $15 copayment for each physical therapy visit. You say that you have already paid these copayments and are being billed for these services again, but no proof of payment was submitted. 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 physical therapy services provided on August 3, 2021, and August 16, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the pelvic x-ray provided on August 27, 2021.  You asked the Plan to pay for the services provided. You say that the records support the procedure. The Plan denied your request. The Plan says the claim processed correctly.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.  We find that CPT code 72170 was billed with code 73051. We looked at the file and the rules. CPT code 72170 may be eligible for payment when billed with this code pair. The claim does not show that the code at issue was billed with a modifier suitable for payment. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the pelvic x-ray provided on August 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), bitewing x-ray (D0270), pulp vitality tests (D0460), and incomplete endodontic therapy (D3332) provided from June 23, 2021, to July 7, 2021.  You asked the Plan to pay for the problem focused limited oral evaluation, bitewing x-ray, pulp vitality tests, and incomplete endodontic therapy. You say that you were approved to have the endodontic therapy done and covered at a 100% benefit of $1,153.00. The Plan denied your request. The Plan says these services are not covered by your dental 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. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), bitewing x-ray (D0270), pulp vitality tests (D0460), and incomplete endodontic therapy (D3332) provided from June 23, 2021, to July 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the outpatient hospital services provided on June 24, 2021.  You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the claim denied correctly.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.  In this case, the CPT Code Manual definition of code 99233 is subsequent hospital care for the evaluation and management of a patient. We looked at the file and the rules. The claim lists a place of service as an inpatient hospital. The medical records show that the enrollee was under observation at the time the services were provided. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the outpatient hospital services provided on June 24, 2021.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to pay for emergency services provided in Canada from July 1, 2021, to July 2, 2021.  You asked the Plan to pay for emergency services. You say that you were not aware you needed to submit records. The Plan denied your request. The Plan says no documentation to support these services has been provided.  The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.   We looked at the file and Medicare rules. No medical records have been submitted documenting the services at issue. Without this information, the specific services provided and the amount that can be paid for these services cannot be verified. Based on this information, we decided that Medicare rules for coverage of emergency services have not been met.    Therefore, we decided that the Plan does not have to pay for emergency services provided in Canada from July 1, 2021, to July 2, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for outpatient mental health services provided on April 4 to April 25, 2021.  You asked the Plan to waive the copayments for outpatient mental health services. You say that the provider is gouging the price of your treatments. The Plan denied your request. The Plan says the correct copayments were 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 a $25 copayment for each individual or group therapy visit for Medicare-covered outpatient mental health services.   You have been asked to pay a $25 copayment for each instance of outpatient mental health services on 4 dates of service. 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 outpatient mental health services provided on April 4 to April 25, 2021.   Your complaint about the provider presenting a bill to you for several months of copayments at once 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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay an additional amount for the comprehensive oral evaluation (D0150), panoramic x-ray (D0330), bitewing x-rays (D0274), initial periapical x-ray (D0220), and additional periapical x-ray (D0230) provided on September 23, 2020.  You asked the Plan to pay an additional amount for the dental services. You say that you are being billed $28 by the provider for services that you received last year. You also say that you were given a receipt that you had a $0 balance. The Plan denied your request. The Plan says there is a maximum benefit of $240 per calendar year for preventive dental services. The Plan says that you are responsible for 100% of all charges once the $240 annual benefit amount is reached.  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 maximum benefit of $240 per calendar year for preventive dental services has been exceeded. The record shows that the Plan paid $65 for dental services you received on October 7, 2020, and $175 for dental services you received on September 23, 2020. $65 + $175 = $240. You are responsible for any amount over the $240 benefit. Therefore, we decided that the Plan does not have to pay an additional amount for the comprehensive oral evaluation (D0150), panoramic x-ray (D0330), bitewing x-rays (D0274), initial periapical x-ray (D0220), and additional periapical x-ray (D0230) provided on September 23, 2020.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the computed tomography (CT) of the head/brain (70450) provided on August 14, 2021.  You asked the Plan to pay for the CT of the head/brain. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says an edit exists between CPT codes 70450 and 70496.  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, we have confirmed that code 70450 is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) of the head/brain (70450) provided on August 14, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a first hour of neuropsychological testing evaluation services (96132), seven additional hours of neuropsychological testing evaluation services (96133 x7), first 30 minutes of psychological or neuropsychological test administration and scoring (96136), and twelve additional 30-minute increments of psychological or neuropsychological test administration and scoring (96137 x12).  You asked the Plan to pre-approve the neuropsychological testing services. You say that you do not understand why you would be denied the neuropsychological testing, as you were diagnosed with vascular dementia in 2012. The Plan denied your request. The Plan says there is nothing in the submitted clinical to substantiate the need for repeat testing. The Plan also says that these services are not medically reasonable or 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 neuropsychological testing. Our reviewer says that the neuropsychological testing services are not considered medically reasonable and necessary in this case. Our physician reviewer found you have a diagnosis of Vascular Dementia (R41.3) and the documentation shows you had neuropsychological testing performed in 2012 which showed mild deficits in cognitive flexibility including attention span and multitasking, memory including conversations. Our reviewer found that you were previously evaluated and found to have cognitive deficits with memory issues which were quantified in 2019. Our physician reviewer also found that the request for neuropsychological testing is not medically necessary or reasonable as information presented in 2012 is sufficient for the decision making process for your treatment.  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 neuropsychological testing have not been met. Therefore, we decided that the Plan does not have to pre-approve a first hour of neuropsychological testing evaluation services (96132), seven additional hours of neuropsychological testing evaluation services (96133 x7), first 30 minutes of psychological or neuropsychological test administration and scoring (96136), and twelve additional 30-minute increments of psychological or neuropsychological test administration and scoring (96137 x12).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for acupuncture, initial 15 minutes (97810) provided September 7, 2021.  You asked the Plan to waive the copayment for the acupuncture services. You say that you feel that you should not have to pay because you were not aware of out-of-pocket costs. The Plan denied your request. The Plan says this claim was processed with the correct copayment applied per the Evidence of Coverage.  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 for each Medicare covered visit.   You have been asked to pay $20 for the acupuncture services. The acupuncture service falls within the Acupuncture for chronic low back pain 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 acupuncture, initial 15 minutes (97810) provided September 7, 2021.
Appeal type: Imaging
Decision: Favorable

 We decided that the Plan has to pay for the magnetic resonance imaging (MRI) services (73721) provided on June 21, 2021.  You asked the Plan to pay for MRI services. You say that you believe that the services you received should be covered. The Plan denied your request. The Plan says that the claim has denied correctly based on billing issues.  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. In this case, the Plan has indicated that the provider in question who rendered the services was contracted with the Plan. There is no evidence that the Plan requested medical documentation regarding the services that were rendered. The Plan must make reasonable and diligent efforts to gather information regarding the decision to deny payment for these services. In addition, the Plan did not forward a claim to show how these services were actually billed. With this necessary information missing, we cannot evaluate the Plan's decision to deny coverage based on billing issues.  Therefore, we decided that the Plan has to pay for the magnetic resonance imaging (MRI) services (73721) provided on June 21, 2021.   If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copay for the laryngoscopy provided on July 8, 2021.  You asked the Plan to waive the copay for the laryngoscopy. You say that you were of the belief there would only be a $45 copayment. The Plan denied your request. The Plan says that the claim processed 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 $325 copay for each Medicare-covered outpatient surgery at a hospital outpatient facility.   You have been asked to pay a $154.91 copay for the laryngoscopy. The laryngoscopy falls within the Medicare-covered outpatient surgery at a hospital outpatient facility benefit category. This means that you have been asked to pay less than 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 copay for the laryngoscopy provided on July 8, 2021.