Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0483) provided on August 3, 2020.
You asked the Plan to pay for drug testing. You say that this was medically necessary. The Plan denied your request. The Plan says this was billed with an incorrect POS.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the records show that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing (G0483) provided on August 3, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the Aspirin, chewable, 81 mg tablet provided on December 18, 2020.
You asked the Plan to pay for the self-administered drug. You say that no one is able to tell you what service was denied. The Plan denied your request. The Plan says the drug you received is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the drug you received is not covered under Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the Aspirin, chewable, 81 mg tablet provided on December 18, 2020.
Benefits for the self-administered drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the recliner chair provided by an out-of-network provider on December 18, 2020.
You asked the Plan to pay for the recliner chair. You say that you would like to recover as soon as possible, and the hospital doctor recommended the recliner. You say that insurance should approve reimbursement based on the medical necessity. The Plan denied your request. The Plan says in-network providers were available to provide the same service.
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 the recliner chair provided by an out-of-network provider on December 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a teeth cleaning (D1110) provided on December 22, 2020
You asked the Plan to pay for a teeth cleaning. You say that you thought the teeth cleaning would be covered by the Plan. The Plan denied your request. The Plan says the service at issue is a covered benefit, however the benefit maximum had already been met.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a teeth cleaning have not been met. Specifically, the record shows that you had exhausted your dental benefit maximum prior to this date of service. Therefore, we decided that the Plan does not have to pay for a teeth cleaning (D1110) provided on December 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal scalings and root planings of four or more teeth per quadrant (D4341) for the upper right quadrant and the upper left quadrant.
You asked the Plan to pre-approve the scalings and planings. You say that you would like these services to be approved for coverage. The Plan denied your request. The Plan says these services 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 scalings and planings 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 scalings and planings. Our reviewer says that the service at issue is not medically reasonable and necessary. Our physician reviewer found the upper right quadrant has three remaining teeth, and the upper left has one remaining tooth. Our reviewer found that the code provided, D4341, is reserved for cases where there are four or more involved teeth in a quadrant. In this case there are less than four teeth in any quadrant, periodontally involved or not. Our physician reviewer also found that the code used is not appropriate. 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 scalings and planings have not been met. Therefore, we decided that the Plan does not have to pre-approve periodontal scalings and root planings of four or more teeth per quadrant (D4341) for the upper right quadrant and the upper left quadrant.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for specialist services provided on February 5, 2019, to November 9, 2020 by an out of network (OON) provider.
You asked the Plan to pay for specialist services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says there are in-network providers available for these services. The Plan says that these services were not emergent in nature.
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 specialist services provided on February 5, 2019, to November 9, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve blepharoplasty, upper eyelid (CPT code 15822).
You asked the Plan to pre-approve the surgery. You say that you hit your head due to the low eyelid, and it is affecting your sight. The Plan denied your request. The Plan says the Medicare rules have not been met.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the surgery. Our physician reviewer found the provided record does not provide sufficient information in order to determine whether the coverage criteria are satisfied. The requested service cannot be recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve blepharoplasty, upper eyelid (CPT code 15822).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the personal care services provided on August 4, 2020.
You asked the Plan to pay for the personal care services. You say that the enrollee switched coverage and the facility was not notified. The Plan denied your request. The Plan says this service is not covered.
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from trained medical or paramedical staff, 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, we find that the services at issue in this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pay for the personal care services provided on August 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on November 12, 2020 by an out of network provider.

You asked the Plan to pay for the office visit. You say that you would like the Plan to pay this claim. The Plan denied your request. The Plan says you did not request authorization.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the office visit provided on November 12, 2020 by an out of network provider.
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 fever, weakness and chills and was treated for cellulitis and abscess. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction (92015) provided on October 13, 2020.
You asked the Plan to pay for the eye refraction. You say that you were told that refractions are covered by your Plan. The Plan denied your request. The Plan initially said this service should be submitted to the supplemental vision plan for review. The Plan also states that eye refractions are not covered under Original Medicare. The Plan has indicated that the provider has been advised to cease billing you for this service and has been informed of the coverage guidelines. This claim was processed correctly.
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 routine eye refractions through an optional supplemental routine vision benefit.
We looked at the file and the Plan's rules. Medicare does not cover eye refractions. The eye refraction provided does not appear to be routine as it was provided with other medical and diagnostic testing services. The Plan reviewed your case and has determined that you should not be held liable for this service, but the Plan does not have to pay for it based on Medicare and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for the eye refraction (92015) provided on October 13, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (80307) provided November 29, 2020 to December 2, 2020.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim was not billed with the correct CPT code.
The Plan must follow Medicare rules. Medicare rules say that to report a CGP, service providers should use CPT code 81479. We looked at the file and Medicare rules. The genetic testing was not billed with CPT code 81479. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (80307) provided November 29, 2020 to December 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on November 9, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not approved in advance.
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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided by an out-of-network provider on November 9, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on November 20, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided by an out-of-network provider on November 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for IV tubing (S1015) and infection control supplies (S8301) provided on December 1, 2020.
You asked the Plan to pay for the IV tubing and infection control supplies. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT codes S1015 and S8301 have status codes of I and are not valid for Medicare purposes.
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 S1015 and S8301 are not supported in the record. Specifically, per the Physician Fee Schedule, CPT codes S1015 and S8301 have status codes of I. This means that these codes are not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the IV tubing and infection control supplies have not been met. Therefore, we decided that the Plan does not have to pay for IV tubing (S1015) and infection control supplies (S8301) provided on December 1, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the personal care services provided on August 12, 2020.
You asked the Plan to pay for the personal care services. You say that the enrollee switched coverage and the facility was not notified. The Plan denied your request. The Plan says this service is not covered.
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from trained medical or paramedical staff, 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, we find that the services at issue in this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pay for the personal care services provided on August 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment and coinsurance for an outpatient surgery and an injection provided by a participating provider on November 19, 2020.
You asked the Plan to waive the copayment for an outpatient surgery and coinsurance for an injection. You say that you do not know why they charged for 60 vials. The Plan denied your request. The Plan says the correct charges have been applied.
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 $295 copayment for outpatient surgery/outpatient hospital and a 20% coinsurance for Medicare Part B prescription drugs. The enrollee has been asked to pay $54.62 which is less than your copayment amount of $295 for an outpatient surgery. You have also been asked to pay a 20% coinsurance of the allowed amount for an injection. The total allowed amount is $1,207.38. The amount you are being asked to pay for an injection is $241.48 ($1,207.38 x 20% = $241.48). The total amount you are being asked to pay is $296.10 ($241.48 + $54.62 = $296.10). The injection that was received is considered an outpatient surgery. An outpatient surgery falls within the outpatient surgery/outpatient hospital benefit category and an injection falls within the Medicare Part B prescription drugs 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 copayment for an outpatient surgery and coinsurance for an injection provided by a participating provider on November 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the digital hearing aids (V5259) purchased on August 28, 2020.

You asked the Plan to pay for the hearing aids. You say that you believed you would be reimbursed $1,400 for these hearing aids based on your plan contract. The Plan denied your request. The Plan says hearing services and hearing aids are not covered when they are received out-of-network.

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 when they are received from the Plan's specified hearing vendor. 

We looked at the file and the Plan's rules. These hearing aids were not purchased from the Plan's hearing vendor as specified in the contract. 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 digital hearing aids (V5259) purchased on August 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cleaning (D1110) and periodic oral evaluation (D0120) provided on January 21, 2021.
You asked the Plan to pay for the dental services. You say that this provider was in-network the last time you saw them, and no one informed you of the change in network status. The Plan denied your request. The Plan says this provider is out-of-network and dental services will only be covered when they are received in-network.
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, items or services received from out-of-network providers are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the cleaning (D1110) and periodic oral evaluation (D0120) provided on January 21, 2021.