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

We decided that the Plan does not have to pay for ophthalmology services provided on October 22, 2020, by an
OON provider.
You asked the Plan to pay for ophthalmology services. You say that you would like this claim reprocessed and
paid. The Plan denied your request. The Plan says services rendered by non-participating providers require
prior authorization as outlined in the enrollee's EOC.
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 ophthalmology services provided on October 22,
2020, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (97530) provided on June 17, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services
cannot be verified.
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 97530 is "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 97530 is "Therapeutic activities, direct (one-on-one)
patient contact (use of dynamic activities to improve functional performance), each 15 minutes".
We asked our coding 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 pay for the services. Our reviewer says that the use of code 97530 is not supported by the records provided. Our coding reviewer found that the medical records document that this service was performed in a home health or hospice setting. Code 97530-GO (4 units) is not the most appropriate code to use to bill this service, therefore, this service is not eligible for reimbursement consideration. There is a more appropriate Healthcare Common Procedural Coding System (HCPCS) code that should be used to bill this service. We looked at this coder's review, the file, and Medicare rules. 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 services (97530) provided on June 17, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home sleep study.
You asked the Plan to pre-approve a home sleep study. The Plan denied your request. The Plan says this is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that home sleep studies are covered for the indications established in the applicable LCD. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a home sleep study. Our reviewer says that the requested home sleep study is not medically reasonable and necessary in this case. Our physician reviewer found that the enrollee is a 64-year-old female with a history of paroxysmal atrial fibrillation. It was noted that the enrollee had a negative sleep study in the past performed by her prior doctor, although the enrollee did not recall this. Sleep disturbance was listed in the assessment. A home sleep study was requested. Based on the provided documentation, there was insufficient support made for a home sleep study. The prior sleep study was not provided for review, and there was no report of classic signs or symptoms of sleep apnea or changes in symptoms since the last test to justify repeat testing. Therefore, the LCD coverage criteria are not met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a home sleep study have not been met. Therefore, we decided that the Plan does not have to pre-approve a home sleep study.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on March 4, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a duplicate claim.
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. We looked at the file and Medicare rules. The services in question were billed on a duplicate claim to one previously processed and paid by the Plan. Duplicate claims are not payable. 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 services provided on March 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the surgical placement of an implant (D6010) provided on December 29, 2020.
You asked the Plan to reimburse you for the dental service. You say that you did not receive reimbursement for the implant. You say that this service was medically required in your case. You say that your dentist advised the service was urgent. You also say that The Plan denied your request. The Plan says the surgical placement of an implant is not listed 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 reimburse you for the surgical placement of an implant (D6010) provided on December 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve implant placements (D6010) for teeth # 6, 14, 15, 19, and 20.
You asked the Plan to pre-approve the dental services. You say that you need the implants. The Plan denied your request. The Plan says the implants are not medically necessary.
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 dental services when the services are medically necessary and reasonable. 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 dental services. Our reviewer says that the implants are not medically necessary. Our physician reviewer found the documentation provided does not indicate that the implants are to support a denture. The reviewer also found that there are more than 1 tooth missing in each arch. Therefore, the reviewer found that the requested implants are not medically reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does not have to pre-approve implant placements (D6010) for teeth # 6, 14, 15, 19, and 20.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from December 5 to
December 9, 2020.
You asked the Plan to pay for acute inpatient hospital care. You say that the requested inpatient care was a
medical necessity for the enrollee. The Plan denied your request. The Plan says that rules for payment have not
been met because the requested care was not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.
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 pay for acute inpatient hospital care. Our reviewer
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician
reviewer found that the record shows that, at the time of inpatient admission, the admitting physician
reasonably expected that the enrollee's necessary hospital care (including earlier emergency department and/or
observation care) would span two midnights.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan
has to pay for the acute inpatient hospital care provided from December 5 to December 9, 2020.
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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from January 25, 2021, to January 31, 2021.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee required no nursing services which would be considered skilled services by Medicare.
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 pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did 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. Based on this information, we decided that Medicare rules for coverage of the skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from January 25, 2021, to January 31, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from December 13, 2020, to December 31, 2020.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee did not require or receive skilled nursing and therapy services.
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 pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did 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. Based on this information, we decided that Medicare rules for coverage of the skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from December 13, 2020, to December 31, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-share for the eye exam (92014) and the eyeglasses (V2304, V2750, V2755) provided on March 3, 2021.
You asked the Plan to waive the cost-share for the eye exam and glasses. You say that you have a yearly checkup for your type 2 diabetes. You needed this visit to check for any deterioration of your condition and to investigate an issue with your eye. You will not need another appointment this year, and request that the Plan cover this as your routine eye exam. The Plan denied your request. The Plan says your benefits were applied correctly, and the Plan owes no additional payment.
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 $30 copayment for a diabetic retinopathy screening exam. Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers up to $220 per year for routine eyewear. You have been asked to pay a $30 copayment for the eye exam. The eye exam was billed with a medical code, and you stated that this exam was because of your diabetes. The Plan requires a $30 copayment for one diabetic retinopathy screening exam per calendar year. This means that you have been asked to pay the correct amount based on your contract with the Plan.
You have been asked to pay $85 for the eyeglasses. The provider billed a total of $305 for the eyeglasses. The Plan paid the full allowance amount of $220. You are responsible for the remaining cost ($305 - $220 = $85). This means that you have been asked to pay the correct amount based on your contract with the Plan.
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost-share for the eye exam (92014) and the eyeglasses (V2304, V2750, V2755) provided on March 3, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eight (8) additional PT visits.
You asked the Plan to pre-approve eight (8) additional PT visits. You say that the PT is medically necessary. The Plan denied your request. The Plan says eight (8) additional PT visit are 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 eight (8) 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 the additional requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health Plan. The enrollee has had prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. The enrollee should be able to transition to a home exercise program with the 2 out of 10 approved therapy sessions. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of eight (8) additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve eight (8) additional PT visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the inhalation of nitrous oxide/analgesia (D9230) provided on February 22, 2021.
You asked the Plan to pay for the inhalation of nitrous oxide/analgesia. You say that you did not receive, nor were you offered, any nitrous oxide/analgesia. The Plan denied your request. The Plan says this service is 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 pay for the inhalation of nitrous oxide/analgesia (D9230) provided on February 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrical stimulator supplies provided to the enrollee on March 21, 2021.
You asked the Plan to pay for the electrical stimulator supplies. You say that this should be separately payable from the TENS unit. The Plan denied your request. The Plan says that this was denied because it is included with the primary procedure, CPT code E0730 (TENS unit).
The Plan must follow Medicare rules. Medicare rules say that during the rental of a TENS unit, supplies for the unit are included in the rental allowance; there is no additional allowance for electrodes, lead wires, batteries, etc. We looked at the file and Medicare rules. The file indicates the Plan approved the rental of a TENS unit. The allowance for the supplies for the unit are included in the rental allowance. Based on this information, we decided that Medicare rules for coverage of the electrical stimulator supplies have not been met. Therefore, we
decided that the Plan does not have to pay for the electrical stimulator supplies provided to the enrollee on March 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the compression stockings and wraps identified with codes A6530 and A6545 that were issued on February 9, 2021 and February 17, 2021.
You asked the Plan to reimburse you for the compression stockings or wraps. You say that the Plan should reimburse you.The Plan denied your request. The Plan says the Plan does not cover compression stockings and also, they were not purchased through a Medicare certified provider.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 A6545 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to reimburse you for the compression stockings and wraps identified with codes A6530 and A6545 that were issued on February 9, 2021 and February 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan of the abdomen and pelvis you had on September 3, 2020.
You asked the Plan to waive the copayment for the CT scan. You say that you were told you would not have to pay any copays and that you cannot afford this amount. 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 $195 copayment for diagnostic imaging services.
You have been asked to pay a $195 copayment for the CT scan. The CT scan falls within the diagnostic imaging services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan of the abdomen and pelvis you had on September 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a telehealth visit (99214) provided on January 28, 2021.
You asked the Plan to pay for a telehealth visit. You say that Medicaid providers have been instructed to use
the POS code for the enrollee's home for telehealth services. The Plan denied your request. The Plan says
Medicare requires POS code 02 for telehealth services.
The Plan must follow Medicare rules. Medicare rules say that providers should submit telehealth services
claims using Place of Service (POS) 02-Telehealth to indicate they furnished the billed service as a
professional telehealth service from a distant site.
We looked at the file and Medicare rules. The telehealth service at issue was not billed with POS 02. Based on this information, we decided that Medicare rules for coverage of a telehealth visit have not been met. Therefore, we decided that the Plan does not have to pay for a telehealth visit (99214) provided on January 28, 2021.