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

We decided that the Plan does not have to pay forprescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens, both eyes, except for aphakia (CPT Code 92310) provided on January 30, 2020. You asked the Plan to pay forthe services. You say that the entire claim, including the contact lens exam and fitting fee should be paid and that you should only be responsible for your copay.The Plan denied your request. The Plan says the service is not a covered benefit under the plan.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. 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 services have not been met. The Health Plan asserts the claim in question is for cosmetic contact lenses. Neither Medicare nor the Health plan cover contact fitting fees for cosmetic lenses. Therefore, the claim line item for the contract lens exam and fitting fee denied correctly and you remain responsible for the full $30 charge. You are responsible for a $35 copay for the routine eye exam, and the $30 charge for the contract lens exam and fitting fee as it is not covered.Therefore, we decided that the Plan does not have to pay forprescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens, both eyes, except for aphakia (CPT Code 92310) provided on January 30, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Orthovisc (J7324).You asked the Plan to pre-approve Orthovisc. You say that this should be covered.The Plan denied your request. The Plan says you have not met step therapy requirements.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.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 Orthovisc. Our reviewer says that the criteria for coverage of Orthovisc have not been met. Our physician reviewer found the Plan requires a trial of Synvisc, Durolane, and Gelsyn-3 before they will approve the requested drug. The provided medical records do not indicate that you have tried the Plan's required drugs or that these drugs would likely be less effective or likely have adverse effects.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Orthovisc have not been met.Therefore, we decided that the Plan does not have to pre-approve Orthovisc (J7324).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe x-ray services coded 74018 provided on December 20, 2010 and December 26, 2019.You asked the Plan to pay forthe x-ray 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 included in the payment of other services.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 74018 for the x-ray services has a bundled relationship with code 74240 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay forthe x-ray services coded 74018 provided on December 20, 2010 and December 26, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe limited oral evaluation (D0140) and the root canal (D3330) provided on January 22, 2020.You asked the Plan to pay forthe limited oral evaluation and root canal. You say that the provider advised that the root canal would not be covered under your plan. You also say that you chose this plan because the provider was in network and "comprehensive" services were covered up to $1,000.You also say that nowhere on the website does it indicated what "comprehensive coverage" does not cover.The Plan denied your request. The Plan says limited oral evaluations are covered once per plan year. The Plan says that the frequency limit has been exceeded. The Plansays that the root canal is not listed as a covered service.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 limited oral evaluations are a covered service, the frequency limit of once per plan year had been exceeded. The record shows that the Plan paid for a limited oral evaluation that you received on January 8, 2020. Additionally, the root canal is not among those covered under this benefit.The Evidence of Coverage clearly states that any services not listed are not covered. Therefore, we decided that the Plan does not have to pay forthe limited oral evaluation (D0140)and the root canal (D3330) provided on January 22, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approveradical nephrectomy (50546).You asked the Plan to pre-approveradical nephrectomy. You say that the services are necessary.The Plan denied your request. The Plan says that medical necessity has not been established. Therefore, coverage criteria has not been met.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 radical nephrectomy. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found this enrollee requires left nephrectomy given the size of the kidney stone (6 cm) with limited renal function and co-existing large 6 cm cyst. The request is not for cyst removal, but the cyst would be taken with the kidney. The primary indicationis the large renal stone.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of radical nephrectomy have been met.Therefore, we decided that the Plan has to pre-approveradical nephrectomy (50546).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe initial hospital care services coded 99222 provided on January 12, 2020.You asked the Plan to pay forthe initial hospital care 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 eligible for reimbursement.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 99222 for the initial hospital care services have a bundled relationship with code 99223 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay forthe initial hospital care services coded 99222 provided on January 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe excision of sublingual gland provided on January 10, 2020.You asked the Plan to waive the copayment forthe excision of sublingual gland. You say that the Plan has always paid in the past and you disagree with the charges.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correctamount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $295 copayment for outpatient hospital surgery. You have been asked to pay a $295 copayment for the excision of sublingual gland. The excision of sublingual gland falls within the outpatient hospital 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 forthe excision of sublingual gland provided on January 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that you are requesting coverage for insoles and a pair of shoes. You say that you have rheumatoid arthritis and this had resulted in deformities in your toes. You stated that you have now developed ulcers on your toes and nodules on your feet. You say that you hope the requested orthotics will allow you to move around without pain and avoid being hospitalized for toe removal. You stated that you have been unable to be treated for your leg ulcers recently because of Covid-19 restrictions. You asked the Plan to reconsider your request for the orthotics as you feel that they will allow you to walk without pain. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says that there is no expectation of functional improvement within a reasonable time period.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for continued SNF services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foroffice visit services provided to the enrollee on January 6, 2020.You asked the Plan to pay forthe services. You say that the plan should reconsider payment.The Plan denied your request. The Plan says an approved referral is needed from the primary care physician.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 has network providers available who can provide 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 foroffice visit services provided to the enrollee on January 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 2 heavy duty power wheelchair.
You asked the Plan to pre-approve the wheelchair. You say that you do not agree with the denial, and you are asking the plan to reconsider. The Plan denied your request. The Plan says a group 2 standard power wheelchair will meet your needs.
The Plan must follow Medicare rules. Medicare rules say that HCPCS K0824 is covered when appropriate for the enrollee's weight. In this case, the definition of HCPCS K0824 is: POWER WHEELCHAIR, GROUP 2 HEAVY DUTY, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 301 TO 450 POUNDS The requested wheelchair is meant for people between 301 and and 450 pounds. Your weight is recorded as 265 pounds. Based on this information, we decided that Medicare rules for coverage of the wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 2 heavy duty power wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intravenous moderate sedation (D9239), and 3 additional 15-minute increments of moderate sedation (D9243) provided on January 27, 2020.
You asked the Plan to pay for the dental services. You say that you had to have your dental work re-done. You say that you needed the anesthesia in order to complete the correction. The Plan denied your request. The Plan says there is an annual maximum benefit of $1,000. The Plan says that the annual maximum has been exhausted.
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 sedation services that you received are listed as covered, the annual maximum benefit has been exhausted.
Therefore, we decided that the Plan does not have to pay for the intravenous moderate sedation (D9239), and 3 additional 15-minute increments of moderate sedation (D9243) provided on January 27, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoperative mapping services provided on December 5, 2019.
You asked the Plan to pay for the mapping services. The Plan denied your request. The Plan says the service requires a qualifying procedure be received and covered.
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 38900 is intraoperative identification (eg, mapping) of sentinel lymph node(s) includes injection of non-radioactive dye, when performed (List separately in addition to code for primary procedure). We find that CPT code 38900 is an add-on code. The records do not show that the service was billed with a valid primary procedure. Based on this information, we decided that Medicare rules for coverage of the mapping services have not been met. Therefore, we decided that the Plan does not have to pay for the intraoperative mapping services provided on December 5, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psychiatric services.
You asked the Plan to pre-approve the continued inpatient psychiatric services. You say that the records provided support the need for inpatient psychiatric care. The Plan denied your request. The Plan says the clinical information does not support this level of care.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 continued inpatient psychiatric services. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found , based upon review the records provided, it was not expected this enrollee would improve in a reasonable period of time beyond the dates in question as he was not showing any dangerousness to self or others, no auditory or visual hallucinations and no aggressive behaviors. The enrollee was compliant with medications and treatment with no perceptual abnormalities. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as he did not have any suicidal or homicidal thoughts, delusions or hallucinations or aggressive behaviors. 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 continued inpatient psychiatric services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient psychiatric services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Dexcom G6 sensor for the enrollee.
You asked the Plan to pre-approve the sensor. You say that this is medically necessary. The Plan denied your request. The Plan says there is no information showing that the enrollee has tried the preferred monitor, or is unable to use it for medical reasons.
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 sensor. Our reviewer says that the requested brand of sensor is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no specific medical necessity for the Dexcom brand over the Freestyle Libre Flash brand continuous glucose monitor sensor. 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 sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve the Dexcom G6 sensor for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that your feet hurt constantly. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay forthe emergency department (ED) services rendered on November 18, 2018.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the claim is not filed timely.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service.The record shows that a claim for these services was not filed until March 6, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay forthe emergency department (ED) services rendered on November 18, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the endodontic therapy provided on February 20, 2020 by an OON provider.You asked the Plan to pay for the endodontic therapy. You say that the Plan should have more doctors available in your area if you are paying for the service.The Plan denied your request. The Plan says you must receive services at a participating provider. The Plan also says that they determined there are contracted endodontists within 10 miles of your residence.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 covered when they are received OON.The records show that the provider's office contacted the Plan prior to rendering the services to you, and were informed that they were OON with your plan. Therefore, we decided that the Plan does not have to pay for the endodontic therapy provided on February 20, 2020 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran epidural injection provided on January 13, 2020.You asked the Plan to waive the copayment foran epidural injection. You say that you should only owe a $45 copayment.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 $214 copayment for outpatient surgical procedures provided in an ambulatory surgical center. You received an epidural injection on January 13, 2020. An epidural injection is considered a surgical procedure. Therefore, you are responsible to pay the $214 copayment. You have been asked to pay a $214 copayment for an epidural injection. An epidural injection falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment foran epidural injection provided on January 13, 2020.