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

We decided that the Plan does not have to pay fordeluxe frames (V2020) single vision lenses (V2199) purchased on December 31, 2019.You asked the Plan to pay forthe vision services. You say that you believe that you have $246.60 credit. Please send a check for the $153 for eyeglasses.The Plan denied your request. The Plan says enrollee's must receive their vision services from an in-network provider.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 these services when up to $250 every year for eyeglasses, frames, lenses or contact lenses from an in network provider.We looked at the file and the Plan's rules. vision services must be provided by an in-network provider. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met.Therefore, we decided that the Plan does not have to pay fordeluxe frames (V2020) single vision lenses (V2199) purchased on December 31, 2019
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe skilled nursing facility (SNF) services provided to the enrollee from February 8, 2019 through February 23, 2019 and March 21, 2019 through April 2, 2019.You asked the Plan to waive the copayment forthe SNF services. The Plan denied your request. The Plan says that the claims processed correctly and in accordance with the member's contract.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 $172 copay per day for days 21-100 of skilled nursing facility (SNF) care. The enrollee has been asked to pay a $1,376 copay for the SNF services. The SNF services falls within the days 21-100 of skilled nursing facility (SNF) care benefit category. The enrollee was in a SNF facility for a total of twenty-eight (28) days. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forthe skilled nursing facility (SNF) services provided to the enrollee from February 8, 2019 through February 23, 2019 and March 21, 2019 through April 2, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the treatment of root canal obstruction (D3331) provided on
January 4, 2020.
You asked the Plan to pay for the treatment of root canal obstruction. You say that your provider checked your
insurance and said the procedure was covered. The Plan denied your request. The Plan says this procedure is
not included in the benefits section of your EOC.
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. The Plan confirmed with the provider's office that you were informed
prior to the procedure that this would not be covered, were given a discount, and signed a document that you
would take financial responsibility for this service. Therefore, we decided that the Plan does not have to pay for
the treatment of root canal obstruction (D3331) provided on January 4, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a breast ultrasound (76641) provided on November 4, 2019.
You asked the Plan to pay for the breast ultrasound. 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 units 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. We find that CPT code 76641 is not supported in the record. Specifically, CPT code 76641 has been billed bilaterally. This service may be billed with the bilateral modifier 50 or as 2 units. It is not appropriate to bill 2 units and a bilateral modifier. Based on this information, we decided that Medicare rules for coverage of the breast ultrasound have not been met. Therefore, we decided that the Plan does not have to pay for a breast ultrasound (76641) provided on November 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a high dose influenza virus vaccine (90662) provided on September 30, 2019.
You asked the Plan to pay for a high dose influenza virus vaccine. You say that this was necessary because the enrollee was in a high risk population. The Plan denied your request. The Plan says the enrollee was not 65 years of age or older.
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 90662 is influenza virus vaccine (IIV), split virus, preservative free, enhanced immunogenicity via increased antigen content, for intramuscular use. Per guidance from the Centers for Disease Control, it is licensed specifically for people 65 years and older. We find that CPT code 90662 is not supported in the medical record. Specifically, this vaccine code is for use for people 65 years or older, and the record indicates the enrollee was 58 years old at the time of service. Based on this information, we decided that Medicare rules for coverage of a high dose influenza virus vaccine have not been met. Therefore, we decided that the Plan does not have to pay for a high dose influenza virus vaccine (90662) provided on September 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.You asked the Plan to pre-approve a shower chair. You say that when you were previously receiving physical therapy at your home, you were given a shower chair. Due to normal wear and tear, you say that the chair is now broken. You stated that you are in desperate need of a shower chair as it prevents you from falling in the shower, which could cause you bodily harm, injury, or even death. You say that you are also legally blind which makes your need for another shower chair urgent.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care provided to the enrollee from July 10,
2019 at 4:52PM through July 11, 2019.
You asked the Plan to pay for inpatient hospital care. You say that the claim should be paid. The Plan denied
your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider,
approval is required.
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 inpatient hospital care. Our physician
reviewer found the review indicates that all inpatient care provided after 4:51 pm on July 10, 2019 through
transfer at 5:46 pm on July 11, 2019 was not needed on an emergent basis. The enrollee was hemodynamically
and neurologically stable and appropriate for ambulance transport with monitoring to a plan facility after 4:51
pm on July 10, 209. The post-stabilization care services July 10, 2019 at 4:52PM through July 11, 2019 were
not medically necessary or reasonable. The review has determined that the treating physician did not document
(in the physician notes, on a form, or in an order) that the patient was not stable for transfer on any dates of
service.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of inpatient hospital care have not been met. Therefore, we decided that the Plan
does not have to pay for inpatient hospital care provided to the enrollee from July 10, 2019 at 4:52PM through
July 11, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from September 25, 2019 through October 18, 2019. You asked the Plan to waive the copayment for inpatient hospital care. You say that all three inpatient hospital
claims should be processed as one inpatient hospital claim instead of three different claims. The Plan denied your request. The Plan says the claims were processed accordingly with your 2019 EOC benefits. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received inpatient hospital care from September 25, 2019 to September 29, 2019, October 1, 2019 to October 6, 2019 and October 12, 2019 to October 18, 2019. You are asked to pay a $395 copayment each day, for days 1 to 4 for each hospital admission. 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 inpatient hospital care from September 25, 2019 through October 18, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from November 11, 2019 to November 14, 2019 by the providing facility.You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you should not be responsible for the copayment.The Plan denied your request. The Plan says based on Medicare billing criteria, the claim was billed 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 $200 copayment for inpatient hospital care. You have been asked to pay $200 for the inpatient hospital stay. 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 inpatient hospital stay provided from November 11, 2019 to November 14, 2019 by the providing facility.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Seat Elevator (E2300) Electronic connection (E2311) Expandable Controller (E2377) and Expandable Controller Harness (E2313).
You asked the Plan to pre-approve the wheelchair accessories. You say that you are appealing the denial of the requested services. The Plan denied your request. The Plan says the seat elevator does not serve a primary purpose and electronic connection, expandable controller, and expandable controller harness are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the wheelchair accessories. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not reveal that the enrollee needs a special drive system to drive the power wheelchair, needs to control 3 or more power features through the drive control, needs to operate a special device through the joystick, or is unable to use the control switch that comes with each power feature. The enrollee has sufficient strength and functional ability that indicates she should be able to control the power features on the wheelchair with their own switches. 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 wheelchair accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve Seat Elevator (E2300) Electronic connection (E2311) Expandable Controller (E2377) and Expandable Controller Harness (E2313).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite provided on October 7, 2019.
You asked the Plan to pay for the resin-based composite. You say that you are entitled to two visits per year to your dentist with no charge. The Plan denied your request. The Plan says the service is a covered benefit, but you had exceeded limits set in the subscriber agreement. The Plan also says that per your claim history, the $1,000 benefit maximum had been met prior to the processing of this 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, the Plan offers a $1,000 annual dental benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are responsible for the full charges of any additional dental services. The record shows that you met the annual maximum benefit on September 4, 2019 and your annual maximum benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the resin-based composite provided on October 7, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.You asked the Plan to pre-approve the LTACH services. You say that the provider is telling you that you need a different level of care than the hospital.The Plan denied your request. The Plan says the services needed could be provided in another setting, such as an acute rehabilitation facility, skilled nursing facility, nursing facility, outpatient setting or home care.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that you require services at the LTACH that are not available at the acute care hospital where you are currently receiving care.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 LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for an office or other outpatient visit (99214) and environmental manipulation (90882) provided on October 14, 2019 by an out of network (OON) provider.
You asked the Plan to pay for an office or other outpatient visit and environmental manipulation provided by an OON provider. You say that the services were provided and payment should be rendered. The Plan denied your request. The Plan says prior authorization was not requested or received and the services were not emergent in nature. Therefore, coverage criteria has not been met.
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 for an office or other outpatient visit (99214) and environmental manipulation (90882) provided on October 14, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics provided on May 3, 2019 by the appealing provider.
You asked the Plan to pay for foot orthotics. You say that you were advised the item would be covered. 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 the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pay for foot orthotics provided on May 3, 2019 by the appealing provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for SNF care from October 1, 2019 through
October 30, 2019.
You asked the Plan to waive the copayment for SNF care. You say that you are appealing your cost-share
responsibility for the services you received. The Plan denied your request. The Plan says they confirmed there
were no calls placed to the customer service department after the authorization appeal approval was received.
The Plan states you did not contact the plan regarding your cost share until January of 2020.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance).
Review of the file shows that you received inpatient skilled nursing services from September 27, 2019 to
September 30, 2019 for a total of 4 days. These were days 1 to 4 of skilled care during the benefit period. You
were not assessed a cost share for these dates of service. You received inpatient skilled nursing services from
October 1, 2019 to October 30, 2019 for a total of 29 days. These were days 5 to 33 of skilled care during the
benefit period. You are responsible for a copayment of $160.00 a day for days 21 to 57. You are responsible for
the copayment for the last 13 days of this stay. You should have been responsible for a copayment of $2,080
($160.00 x 13 days), however you reached your out-of-pocket maximum with the processing of this claim and
was only assessed the remaining amount of $1,526.38. 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
SNF care from October 1, 2019 through October 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an annual wellness visit (G0439) provided on December 5, 2019. You asked the Plan to pay for the annual wellness visit. You say that you would like reconsideration because payment for this service should be the responsibility of the Plan. The Plan denied your request. The Plan says this service is covered benefit but you exceeded the limits set in the subscriber agreement for number of annual wellness visits.
The Plan must follow Medicare rules. Medicare rules say that a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information. We find that CPT code G0439 is not supported in the record. Specifically, the record indicates that you received an annual wellness exam on July 19, 2019. The second annual wellness exam received on December 5, 2019 exceeds the benefits limits outlined in your EOC. Based on this information, we decided that Medicare rules for coverage of the annual wellness visit have not been met. Therefore, we decided that the Plan does not have to pay for an annual wellness visit (G0439) provided on December 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on December 13, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use. The record shows that documentation submitted did not indicate the provider discussed the need for the billed supply code, so the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on December 13, 2019.