Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the prophylaxis provided on January 25, 2021.
You asked the Plan to pay more for the prophylaxis. You say that you would like to be reimbursed in full for
this service. The Plan denied your request. The Plan says you paid $132.00 for the prophylaxis, the Plan
applied a 50% coinsurance, and reimbursed you $66.00 on January 28, 2021.
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 a 50%
coinsurance when you receive cleanings in-network. Therefore, we decided that the Plan does not have to pay
more for the prophylaxis provided on January 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided on January 27, 2021, and January 28, 2021.

You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that you switched from original Medicare and now are being charged extremely high charges. 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 Medicare Part B prescription drugs. 

You received Medicare Part B drugs on January 27, 2021. The total allowed amount is $16,668.64 and 20% of that is $3,333.73. 

You received Medicare Part B drugs on January 28, 2021. The total allowed amount is $3,213.43 and 20% of that is $642.69. 

The total amount you owe is: $3,976.42. 

You have been asked to pay the total coinsurance amount of $3,976.42 for Medicare Part B drugs. Medicare Part B drugs fall within the Medicare Part B prescription drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided on January 27, 2021, and January 28, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 80053, 80061, 84443, and
85025 provided on October 8, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT codes 80053, 80061, 84443, and 85025 are not supported in the medical record. Specifically,
documentation was not provided to the Plan to support medical necessity of the services rendered. Based on
this information, we decided that Medicare rules for coverage of the laboratory services have not been met.
Therefore, we decided that the Plan does not have to pay for the laboratory services coded 80053, 80061,
84443, and 85025 provided on October 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) received September 29, 2020.
You asked the Plan to pay for the comprehensive periodontal evaluation. You say that the requested service should be paid for by the Plan. The Plan denied your request. The Plan says only the services listed in your dental rider are covered by the Plan. The requested service is not listed among your 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 the comprehensive periodontal evaluation (D0180) received September 29, 2020.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care services provided on
October 26, 2020.
You asked the Plan to pay for the subsequent nursing facility care services. You say that you would like the
plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee was enrolled in
hospice.
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 October 21, 2020. The services in question were provided
before the end of that month. Therefore, we decided that the Plan does not have to pay for the subsequent
nursing facility care services provided on October 26, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the emergency room visits provided from November 30, 2020 and December 1, 2020.
You asked the Plan to waive the copayments for the emergency room visits. You say that the enrollee should not be responsible for the copayments. The Plan denied your request. The Plan says you have been asked to pay 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $120 copayment for emergency care. The enrollee has been asked to pay a $120 copayment for the emergency room visit on each date of service. The emergency room visits fall within the "Emergency 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 copayments for the emergency room visit provided from November 30, 2020 and December 1, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on January 19, 2021.

You asked the Plan to waive the copayment for laboratory services. You say that you disagree with the charges because the laboratory services should be included in the annual wellness exam. 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 $10 copayment for laboratory services. 

You received laboratory services on January 19, 2021. Laboratory services are not included in an annual wellness exam. Therefore, you are responsible to pay the $10 copayment. 

You have been asked to pay a $10 copayment for laboratory services. Laboratory services fall within the outpatient diagnostic tests and therapeutic services and 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 copayment for laboratory services provided on January 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and the prophylaxis (D1110) provided on December 30, 2020.
You asked the Plan to pay for the dental services. You say that your coverage includes 2 dental hygiene visits per year. You say that this was your second one. You say that you were advised by a plan representative that this visit would be covered by your original policy plan. You say that the Rider covered nothing and and the dental work you had in October was applied to your original policy and not the Rider. The Plan denied your request. The Plan says you were enrolled in the optional dental rider from July 1, 2020, to July 31, 2020. The Plan says that the Routine Dental Benefit has a $500 annual maximum for covered dental services. The Plan also says that the annual maximum benefit was exhausted prior to the processing of this claim.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage and the services are listed as covered, the annual maximum benefit of $500 for Routine Dental Coverage has been exceeded.
The Evidence of Coverage clearly states that after the annual maximum is exhausted, any remaining charges are your responsibility. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and the prophylaxis (D1110) provided on December 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids (V5260) provided on January 12, 2021.
You asked the Plan to pay for the hearing aids. You say that you did not know about the Plan's specified hearing provider and went to the provider that you had already used for several years. The Plan denied your request. The Plan says hearing aids will only be covered when they are an approved model provided by the specified supplemental hearing vendor. You purchased hearing aids from a different provider. Therefore, they cannot be covered.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only they are the specified models purchased from the Plan's specified hearing provider. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids (V5260) provided on January 12, 2021.
Your complaint about the Plan's specified provider and what is or is not eligible for coverage under the Plan's supplemental benefit 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for sales tax for the seat lift purchased October 28, 2020.
You asked the Plan to pay for sales tax. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says this claim has processed correctly as Medicare does not cover sales tax.
The Plan must follow Medicare rules. Medicare rules say that Medicare does not reimburse separately for sales tax. We looked at the file and Medicare rules. Based on this information, we decided that the claim has processed correctly as Medicare does not reimburse separately for sales tax. Therefore, we decided that the Plan does not have to pay for sales tax for the seat lift purchased October 28, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve Strabismus surgery (a type of eye surgery).
You asked the Plan to pre-approve Strabismus surgery. You say that you are appealing with supporting records. The Plan denied your request. The Plan says that the denial of authorization for this service is correct, because the enrollee has not tried and failed full prism therapy with her glasses to treat her double-vision.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Strabismus surgery. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is symptomatic with diplopia and has a deviation that is correctable with surgery. The enrollee has used glasses with prism, yet the symptoms have persisted. The Plan's argument that the enrollee must have tried and failed treatment with prismatic glasses is arbitrary and not supported by medical literature. Even if coverage for this surgery were held to this standard the enrollee has met these criteria. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Strabismus surgery have been met. Therefore, we decided that the Plan has to pre-approve Strabismus surgery (a type of eye surgery).
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: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for the personal care services (T1019) provided on August 19, 2020.

You asked the Plan to pay for the personal care services. You say that you would like reconsideration because you were not aware that the member's authorization had ended. The Plan denied your request. The Plan says this is not part of the plan benefit package.

The Plan must follow Medicare rules. Medicare rules say that custodial care is not covered. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the personal care services have not been met. Specifically, the billed services are custodial care services which are not covered by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the personal care services (T1019) provided on August 19, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on June 18, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.

The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. 

We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on June 18, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the COVID-19 testing provided on august 25, 2020.

You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that testing required by third parties is not covered. 

We looked at the file and Medicare rules. The requested COVID-19 testing was required by a third party. This is not a covered by Medicare or the Plan. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for the COVID-19 testing provided on august 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay in full for the periodic oral evaluation and prophylaxis provided on January 19, 2021 by an OON provider.

You asked the Plan to pay in full for the periodic oral evaluation and prophylaxis. You say that you believe these services should be covered. The Plan denied your request. The Plan says the total $68.00 amount applied correctly as member liability. The Plan also says that cost sharing is a contractual obligation under the Plan and cannot be waived.

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. Therefore, we decided that the Plan does not have to pay in full for the periodic oral evaluation and prophylaxis provided on January 19, 2021 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve liquid sclerotherapy treatments.

You asked the Plan to pre-approve the liquid sclerotherapy. You say that it is felt that sclerotherapy on the distal right leg would be appropriate to treat ongoing reflux. The Plan denied your request. The Plan says the documentation does not indicate the severity score of the enrollee's disease after the ablation procedure.

The Plan follows Medicare rules. Medicare rules say that invasive treatment of varicose veins is only reasonable and necessary when there are life-limiting symptoms. 

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 liquid sclerotherapy. Our reviewer says that the requested vascular intervention is not considered medically reasonable and necessary. Our physician reviewer found the patient is status post bilateral greater saphenous vein ablation and is doing well and without discomfort. Asymptomatic distal reflux following saphenous ablation as not an indication for further procedures. 

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 liquid sclerotherapy have not been met. Therefore, we decided that the Plan does not have to pre-approve liquid sclerotherapy treatments.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for surgical treatment of a hip fracture and elbow fracture after a fall. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a genomic sequence analysis panel (81445) provided on May 26, 2020.
You asked the Plan to pay for genomic sequence analysis panel. You say that this Medicare-covered testing. The Plan denied your request. The Plan says the units billed exceeds MUE.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied. In this case, the MUE for CPT code 81445 is 1. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of genomic sequence analysis panel have not been met. Therefore, we decided that the Plan does not have to pay for a genomic sequence analysis panel (81445) provided on May 26, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services (99152) provided on May 21, 2020.

You asked the Plan to pay for the moderate sedation services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the service billed.

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 99152 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; initial 15 minutes of intraservice time, patient age 5 years or older. 

We find that CPT code 99152 is not supported in the record. Specifically, the documentation does not support the presence of an independent trained observer, therefore; this service cannot be verified. Based on this information, we decided that Medicare rules for coverage of the moderate sedation services have not been met. Therefore, we decided that the Plan does not have to pay for the moderate sedation services (99152) provided on May 21, 2020.