Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ophthalmic diagnostic imaging (the retina scan) you received on December 22, 2020.
You asked the Plan to waive the copayment for the retina scan. You say that retina scanning is necessary to retain your visional health. The Plan denied your request. The Plan says you were charged this copayment 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 $40 copayment for diagnostic procedures and tests in a doctor's office. You have been asked to pay a $40 copayment for the retina scan. The retina scan falls within the diagnostic procedures and tests in a doctor's office 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 ophthalmic diagnostic imaging (the retina scan) you received on December 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an intraoral periapical radiographic image (D0220) provided on March 24, 2021.
You asked the Plan to pay for an intraoral periapical radiographic image. You say that the service was necessary. The Plan denied your request. The Plan says the service at issue is not a covered benefit.
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 an intraoral periapical radiographic image (D0220) provided on March 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited oral evaluation (D0140), and a core buildup (D2950) provided on March 17, 2021.

You asked the Plan to pay for a limited oral evaluation, and a core buildup. You say that the services were necessary. The Plan denied your request. The Plan says the services at issue are not covered 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 a limited oral evaluation (D0140), and a core buildup (D2950) provided on March 17, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve video electroencephalography (EEG) monitoring to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the OON video EEG monitoring. You say that the requested OON provider facility prevents hospitalization during testing, which lowers costs. You say that the OON provider offers mobility services at the enrollee's home, while monitoring them from the office. You say that this allows for safe social distancing during the coronavirus pandemic. You say that other facilities are closed to maintain safety for patients. You say that the clinical notes provided support the need for the services in dispute. The Plan denied your request. The Plan says the documentation indicates that the enrollee's needs can be met in network.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve video electroencephalography (EEG) monitoring to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services received from an out-of-network provider
on January 20, 2021.
You asked the Plan to pay for the services. You say that you were unaware that the services were not preapproved.
The Plan denied your request. The Plan says a prior authorization is required before services are
rendered.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for surgical services received from an out-of-network
provider on January 20, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit provided on March 24,
2021 by an OON provider.
You asked the Plan to pay for the domiciliary or rest home visit. You say that authorization was not obtained
prior to seeing this enrollee because it is the nursing facility's responsibility to obtain authorization for their
patients. The Plan denied your request. The Plan says the treating provider is not a network provider. The Plan
also says that the services were not referred by a network provider or rendered in a participating facility.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the domiciliary or rest home visit provided on
March 24, 2021 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pontic (D6241) and two retainer crowns (D6751 x2).
You asked the Plan to pre-approve the pontic and retainer crowns. The Plan denied your request. The Plan says these services are not covered.
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 pre-approve a pontic (D6241) and two retainer crowns (D6751 x2).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an external ambulatory infusion pump provided on May 12, 2021.
You asked the Plan to waive the coinsurance for an external ambulatory infusion pump. You say that you cannot afford the charges and will have to return the device. 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 20% coinsurance for DME and related supplies. You received an external ambulatory infusion pump on May 12, 2021. An external ambulatory infusion pump is considered DME. Therefore, you are responsible to pay your share of the cost-sharing charges. The total allowed amount is $5,000 and 20% of that is $1,000.
You have been asked to pay the total coinsurance amount of $1,000 for an external ambulatory infusion pump. An external ambulatory infusion pump falls within the 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 external ambulatory infusion pump provided on May 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wheelchair vehicle lift.
You asked the Plan to pre-approve a wheelchair vehicle lift. You say that the enrollee needs a car lift for their
power wheelchair to get from place of place. The Plan denied your request. The Plan says the requested item is
not a covered benefit.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate
and needed for use inside the home.
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not
have to pre-approve a wheelchair vehicle lift.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve window air conditioner unit, for the enrollee.
You asked the Plan to pre-approve the air conditioner. You say that the enrollee has asthma, and pulmonary
fibrosis from a prior illness. You state the recent heat has been making the enrollee's breathing more difficult,
and the enrollee is requesting an air conditioning unit. You state that you believe an air conditioning unit may
improve the enrollee's breathing, and certainly would improve their quality of life. The Plan denied your
request. The Plan says air conditioners are not medical equipment and are not covered.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature.
This item is available to the general public and would be helpful even to those who are not sick or injured.
Therefore, we decided that the Plan does not have to pre-approve window air conditioner unit, for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee from September 22, 2020 to September 25, 2020.
You asked the Plan to pay for this claim. You say that these services should be paid by the Plan. The Plan denied your request. The Plan says they upheld the denial as an appropriate G and Q code were missing on the claim for the billed dates of service. Medicare would expect home health agencies to report the G-code which reflects the service for which most of the time was spent during that visit and the Q-code which reflects where the services were provided.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. Any data element that is missing will cause nonpayment of the claim. In this case, these services cannot be paid due to the omission of the appropriate location codes and time spent codes. Medicare billing criteria are not met. Therefore, we decided that the Plan does not have to pay for home health services provided to the enrollee from September 22, 2020 to September 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the foam dressing, wound covering (A6213) rendered by the out-of-network (OON) provider on April 29, 2021.
You asked the Plan to pay for this item. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the item 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 item at issue in this appeal.
The Plan did not pre-approve the item at issue. We found no exception that would require the Plan to pay for this item. Therefore, we decided that the Plan does not have to pay for the foam dressing, wound covering (A6213) rendered by the out-of-network (OON) provider on April 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services provided on June 22, 2020.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the code may not be paid if furnished to hospital inpatients.
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 99153 is moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List separately in addition to code for primary service). We find that CPT code 99153 is a technical component only code. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the moderate sedation services provided on June 22, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) services you
received on June 17, 2020.
You asked the Plan to waive the copayment for the ER services. You say that your driver did not take you
where you wanted to go- you say you did not intend to go to the ER, but rather to a doctor's office. The Plan
denied your request. The Plan says you were charged this copayment 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 an $80
copayment for emergency room visits.
You have been asked to pay an $80 copayment for the ER services. This copayment applies regardless of how
you ended up at the ER. 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 emergency room (ER)
services you received on June 17, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from October 21, 2020.
You asked the Plan to pay for home health services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says Medicare rules for payment of this claim have not been met as the claims were not initially billed under a UB-04.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, this claim has not been submitted on an appropriate form for Home Health Agency billing. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from October 21, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869), for the enrollee.
You asked the Plan to pre-approve the surgery. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is considered experimental and investigational.
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 surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy of the 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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869), for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for a limited oral evaluation (D0140)
provided on March 30, 2021.

You asked the Plan to pay an additional amount for a limited oral evaluation. You say that you should not have
to pay for this service. The Plan denied your request. The Plan says the claim for this service was processed
correctly with the applicable out-of-network allowable amount paid.

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.

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for
coverage of a limited oral evaluation have not been met. Specifically, the allowed amount of this service for an
out-of-network provider was paid by the plan. Any amount beyond the allowed amount is your contractual
responsibility. Therefore, we decided that the Plan does not have to pay an additional amount for a limited oral
evaluation (D0140) provided on March 30, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the SNF stay.
You asked the Plan to pre-approve the SNF stay. You say that it is unsafe for the enrollee to be outside of a medical facility, and his spouse cannot lift him or push his wheelchair. You also say that you are concerned for the enrollee's safety. The Plan denied your request. The Plan says the requested SNF services are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF stay. Our reviewer says that the enrollee does not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee does not have daily skilled nursing needs that requires the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that requires the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. We looked at this physician's review, the file, and Medicare rules. Although the enrollee has skilled therapy needs, these needs are not on a daily basis. Based on this information, we decided that Medicare rules for coverage of the SNF stay have not been met. Therefore, we decided that the Plan does not have to pre-approve the SNF stay.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a SNF admission.
You asked the Plan to pre-approve the SNF admission. You say that you are confined to a bed, cannot walk, and need assistance using the bathroom and bathing. You also say that you need to be turned in bed every three hours, need your medicines given to you, and you need your food prepared. The Plan denied your request. The Plan says your needs are custodial in nature.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF admission. Our reviewer says that you do not meet the Medicare criteria for SNF care. Our physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. Our reviewer found that you do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. Our physician reviewer also found that you do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. We looked at this physician's review, the file, and Medicare rules. Although you have skilled therapy needs, these needs are not on a daily basis. Based on this information, we decided that Medicare rules for coverage of the SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve a SNF admission.